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A  TREATISE 


ON 


NERVOUS   DISEASES 


THEIR 


SYMPTOMS  AND   TREATMENT. 


A   TEXT-BOOK   FOR    STUDENTS  AND   PRACTITIONERS. 


BY 

SAMUEL   G.  WEBBER,   M.D., 

CLINICAL   INSTRUCTOE   IN  NERVOUS    DISEASES,    HAEVAED   MEDICAL   SCHOOL  ;    VISITING 
PHYSICIAN  FOB  DISEASES   OF  THE  NEEVOUS   STSTEM  AT  THE  BOSTON   CITY   HOS- 
PITAL ;    MEMBEE   OF  THE  MASSACHUSETTS  MEDICAL   SOCIETY  ;    MEMBER 
OF  THE   AMERICAN    NEUEOLOGICAL  ASSOCIATION,    ETC.,   ETC. 


NEW  YORK: 
D.    APPLETON    AND    COMPANY, 

1,  3,  AND  5  BOND  STREET. 

1885. 


COPTEIGHT,  18S5, 

bt  d.  appleton  and  company. 


PREFACE. 


This  book  was  commenced  witli  tlie  purpose  of 
writing  briefly,  and  including  what  is  most  essential 
for  the  study  of  nervous  diseases,  within  as  small  a 
compass  as  possible.  The  limits  originally  marked 
out  have  been  somewhat  exceeded.  The  histories 
of  discoveries,  reports  of  cases,  and  discussions  of 
disputed  points  have  been  omitted ;  the  opinions  of 
different  observers  have  been  alluded  to  only  rarely. 
An  effort  has  been  made  to  describe  the  symptoms 
with  sufficient  detail  to  render  easy  the  recognition  of 
a  case  in  practice.  My  own  views  have  been  formed 
from  observation  and  from  reading  the  opinions  of 
others ;  to  give  proper  credit  in  every  instance  might 
be  impossible.  The  attempt  has  not  been  made.  Of 
course,  in  the  brief  Bibliographies  only  a  few  authors 
could  be  mentioned,  compared  with  the  large  number 
who  have  contributed  to  an  increase  of  our  knowl- 
edge during  the  last  few  years. 

The  book  is  not  written  for  specialists.  Many 
will  probably  find  that  no  department  or  division 
is  so  fully  treated  as  they  may  sometimes  wish.     I 

/^  ^"  4  ^  •  '■" 


iv  PREFACE. 

trust  tliat  students  and  general  practitioners  who 
liave  little  time  to  read  will  find  wliat  they  most 
need  for  diagnosis  and  treatment  of  the  cases  occur- 
ring in  practice.  In  some  parts,  especially  the  intro- 
ductory chapters,  the  condensation  may  seem  to  have 
been  carried  too  far ;  but  more  extensive  descriptions 
would  have  required  an  increase  in  bulk. 

133  BoTLSTON  Street,  Boston, 
June  1,  1885. 


CONTENTS. 


CHAPTER  I. 

PAGZ 

General  Inteoditction         . 1 

Methods  of  Testing  Sensation,  1 ;  Methods  of  Testing  Motion,  5  ; 
Reflexes,  8 ;  Tdche  Ch-ebrale,  9 ;  Cheyne-Stokes  Respiration,  10 ;  Bed- 
Sores,  10;  Constipation,  11 ;  Cystitis,  12;  Nutrition,  12. 


DISEASES   OF  THE  BRAIN. 

CHAPTER  II. 
Inteoditotoey 17 

Anatomy,  18 ;   Physiology,  33 ;  General  Symptomatology,  37 ; 
Disturbances  of  Speech,  46. 

CHAPTER  III. 
Diseases  of  the  Membeanes 50 

External  Pachymeningitis,  50 ;    Internal  Pachymeningitis,  51 ; 
Simple  Inflammation  of  the  Pia  Mater,  53  ;  Tubercular,  61. 

CHAPTER  IV. 

Change  in  Blood-Sitpplt 68 

Cerebral  Anaemia,  68 ;  Cerebral  Hyperemia,  74. 

CHAPTER   V. 
H^moeehage 84 

Meningeal  Haemori-hage,  84;  Cerebral  Haemorrhage,  86. 

CHAPTER  VI. 

OcoLtrsioN  OF  Ceeebeal  Aeteeies 107 

Embolism,  107;  Thrombosis,  112. 


yi  CONTENTS. 

CHAPTER  VII. 

PAGE 

TUMOES   OF   THE   BrAIN 116 

CHAPTER   VIII. 
Absgess  of  the  Beain 124 

DISEASES   OF  THE  SPINAL    CORD. 

CHAPTER  IX. 

Anatomy  of  the  Spinal  Coed 181 

Physiology  of  the  Spinal  Cord,  136  ;  General  Symptomatology, 
138. 

CHAPTER   X. 

Spinal  Meningitis 149 

Pachymeningitis  Interna,  149  ;    Inflammation  of  the  Pia  Mater 
(Leptomeningitis),  152. 

CHAPTER  XL 
Changes  in  Blood-Supply 156 

Spinal  HyperaBmia,  156;  Spinal  Anaemia,  158. 

CHAPTER   XIL 

Spinal  H^moeehage 159 

Meningeal   Haemorrhage,   Hsematorrhachis,   159;    Haemorrhage 
into  the  Spinal  Cord,  HaBmatomyelitis,  162. 

CHAPTER  XIII. 

Slow  Compeession  of  the  Spinal  Coed 167 

Spinal  Tumors,  I'ZS. 

CHAPTER  XIV. 
Syringomyelia. — Formation  of  Cavities. — Hydeomyelus         .     176 

CHAPTER   XV. 

Myelitis,  Acute 179 

Chronic,  188;  Acute  Ascending  Paralysis,  192. 


CONTENTS.  vii 

CHAPTER  XVI. 

PAGE 

■  P0UOMTELITI8.    Myelitis  of  the  Anteeioe  Coenua  ,        .        .    195 

Acute    Anterior  Poliomyelitis,  195 ;    Chronic  Anterior  Polio- 
myelitis, 202. 

CHAPTER  XVII. 
Peogeessive  Mtisculae  Ateophy 207 

CHAPTER  XVIII. 

BuLBAE  Paealysis  (Labio-Glosso-Laeyngeal  Paealysis)  .        .215 
Acute  Bulbar  Paralysis,  222. 

CHAPTER   XIX. 

LocoMOTOE  Ataxia. — Tabes  Doesalis. — Posteeioe  Spinal  Scle- 

Eosis 224 

CHAPTER    XX. 

Scleeosis. — Mtjltiple  Soleeosis 242 

Sclerosis  of  the  Lateral  Columns,  250;   Amyotrophic  Lateral 
Sclerosis,  252. 

CHAPTER  XXI. 
Pseudo-Hypeeteophio  Paealysis         ......    255 


DISEASES   OF  THE  PERIPHERAL  AND   SYMPATHETIC 

NERVES. 

CHAPTER   XXII. 
Simple  Neueitis 261 

Multiple  Neuritis  (Disseminated  Neuritis),  266. 

CHAPTER  XXIII. 
Netjealgia 270 

Trifacial  Neuralgia  (Prosopalgia),  274;  Cervico-Occipital  Neu- 
ralgia, 274 ;  Cervico-Brachial  Neuralgia,  275 ;  Dorso-Intercostal 
Neuralgia,  275 ;  Lumbo-Abdominal  Neuralgia,  276 ;  Sciatica,  276. 


viii  CONTENTS. 

CHAPTER  XXIV. 

FAGB 

Local  and  Post-Febeilk  Paralysis 285 

Peripheral  Paralysis,  285 ;  Special  Forms  of  Paralysis,  289  ; 
Paralysis  of  Ocular  Nerves,  289 ;  Paralysis  of  Seventh  Nerve,  289  ; 
Paralysis  of  the  Brachial  Plexus,  293 ;  Paralysis  after  Acute  Dis- 
eases, 294 ;  Diphtheritic  Paralysis,  295. 

CHAPTER   XXV. 

Spasm 298 

Facial  Spasm,  299  ;  Torticollis,  or  Wry-Neck,  801 ;  Spasm  of 
the  Diaphragm,  303  ;  Professional  Cramp,  304. 

CHAPTER  XXVI. 

Diseases  of  the  Sympathetic "  307 

Cephalalgia,  Headache,  307 ;  Megrim,  Sick  Headache,  Migraine, 
311;  Graves's  Disease  (Exophthalmic  Goitre),  316;  Angina  Pec- 
toris, 318  ;  Symmetrical  Gangrene,  822  ;  Unilateral  Facial  Atrophy, 
324. 


UNCLASSIFIED. 

CHAPTER   XXVII. 
Veetigo 329 

Meniere's  Disease,  830. 

CHAPTER  XXVIII. 
Chorea 832 

CHAPTER  XXIX. 
Paralysis  Agitans. — Shakestg  Palsy. — Paekinson's  Disease    .    839 

CHAPTER   XXX. 
Epilepsy 342 

CHAPTER  XXXI. 
Hysteria , 853 

Hystero-Epilepsy,  360. 


CONTENTS.  ix 

CHAPTER  XXXII. 

PAGE 

Netjeasthenia 371 

CHAPTER   XXXIII. 

Tetantjs  (Locked-Jaw) 379 

Tetany,  383. 

CHAPTER  XXXIV. 
MyxcedemSl 386 

CHAPTER   XXXV. 

TOXIO  NEUK08I8 389 

Chronic  Lead-Poisoning,  890 ;  Arsenic,  394 ;  Alcohol,  395 ; 
Hydrophobia,  399. 

CH^iPTER   XXXVI. 

Stphixis 403 

Syphilis  of  the  Brain,  403 ;  Syphilis  of  the  Spinal  Cord,  408 ; 
Syphilis  of  the  Nerves,  409  ;  Treatment  of  Syphilis  of  the  Nervous 
System,  409. 


A  TREATISE 

ON 

KERVOUS    DISEASES. 


CHAPTER  I. 

GENERAL  INTRODUCTION. 

EuLENBTTRG,  A.,  Lehrbuch.  der  functionellen  Nervenkrank- 
heiten.  Berlin,  1871. — Zibmssen,  Cyclopaedia  of  the  Practice  of 
Medicine.  Vols.  XI,  XII,  XIII,  XIV.— Eosenthal,  M.,  A  Clin- 
ical Treatise  on  the  Diseases  of  the  Nervous  System.  Trans,  by 
L.  Putzel.  New  York,  1879.— Hammond,  William  A.,  A  Treatise 
on  the  Diseases  of  the  Nervous  System.  New  York,  1881. — Ham- 
ilton, A.  McL.,  Nervous  Diseases  :  their  Description  and  Treat- 
ment. Philadelphia,  1881.— Charcot,  J.  M.,  Lectures  on  the  Dis- 
eases of  the  Nervous  System,  delivered  at  La  Salpetriere.  Trans, 
by  George  Sigerson.  New  Sydenham  Society,  1877,  1881. — Gras- 
SET,  J.,  Maladies  du  systeme  nerveux.  1881. — Buzzard,  T.,  Clini- 
cal Lectures  on  Diseases  of  the  Nervous  System.  Philadelphia, 
1883. — AxENFELD,  A.  (Huchard),  Traite  des  nevroses.  Paris,  1883. 
— Ross,  James,  A  Treatise  on  the  Diseases  of  the  Nervous  System, 
2  vols.  New  York,  1883.— Strumpell,  A.,  Erankheiten  des  Ner- 
ven-systems.     Leipzic,  1884. 

It  will  be  an  advantage  to  consider  in  a  general  way 
tlie  methods  of  examining  sensation  and  motion  in  pa- 
tients affected  with  nervous  diseases.  It  will  prevent 
the  necessity  of  repetition  if  certain  symptoms  or  com- 
plications are  also  considered  in  this  introductory 
chapter. 

METHODS  OF  TESTING  SENSATION. 

Changes  of  sensation  of  touch  may  be  recognized 
by  touching  the  patient  as  lightly  as  possible  with  the 
1 


2  A   TREATISE  ON  NEBV0U8  DISEASES. 

finger  or  a  feather.  The  finger  should  be  kept  still,  on 
the  spot  first  touched ;  if  it  is  moved  about,  rubbing 
the  skin,  the  patient  will  much  more  readily  recognize 
that  he  has  been  touched. 

The  temperature  of  the  finger  should  be  as  nearly 
as  possible  equal  to  that  of  the  body ;  otherwise  the 
difference  in  temperature  is  felt. 

Changes  in  the  sensation  of  pressure  may  also  be 
recognized  with  the  finger  by  varying  the  amount  of 
pressure  and  asking  the  patient  whether  it  is  greater 
or  less.  There  are  various  apparatus  for  more  deli- 
cately testing  this  sense  by  means  of  adding  graduated 
weights,  but  these  are  unnecessary  for  ordinary  pur- 
poses. 

In  testing  the  sense  of  pain,  a  pin  or  a  knife  can  be 
used,  or  the  patient  can  be  pinched  with  varying  de- 
grees of  severity.  If  one  or  two  hairs  on  the  patient's 
limbs  are  pulled,  the  sensation  will  be  very  nearly  the 
same  as  if  a  pin  were  stuck  into  that  place. 

Changes  in  the  sensation  of  temperature  may  be  ex- 
amined by  means  of  spoons  dipped  in  tumblers  of  water 
of  different  temperature.  More  delicate  methods  of  ex- 
amining the  variations  in  the  sense  of  temperature  may 
be  found  in  having  small  bottles  full  of  water  of  differ- 
ent temperatures.  The  patient  is  then  asked  whether 
the  temperature  of  one  is  higher  or  lower  than  that  of 
another.  But  these  are  rather  refinements  of  examina- 
tion, which  are  rarely  of  any  great  practical  value. 

The  muscular  sense  may  be  tested  by  asking  the 
patient,  with  his  eyes  shut,  to  move  his  limbs  .in  differ- 
ent directions,  or  to  find  his  feet  in  the  bed,  or,  when 
the  limbs  are  widely  separated,  to  raise  one  foot  and 
put  it  down  by  the  side  of  the  other. 

The  (BstJiesiometer  is  used  in  testing  the  ability  of 
the  patient  to  recognize  whether  one  or  two  points  touch 
the  surface  of  the  body.  A  rough  form  of  eesthesiom- 
eter  may  be  contrived  by  holding  two  pins  in  the  fin- 
gers and,  varying  the  distance  of  their  points,  touching 


GENERAL  INTEODUGTIOK  3 

the  patient  with  them  ;  or  needles  may  be  stuck  in  a 
piece  of  wood,  and  then  the  patient  touched.  There 
are,  however,  many  simple  instruments  for  this  exami- 
nation, as  compasses  with  a  graduated  scale,  or  points 
sliding  on  a  graduated  rod.  In  making  this  examina- 
tion, it  is  necessary  that  both  points  should  touch  the 
skin  together  with  as  nearly  as  possible  equal  force. 
In  examining  the  opposite  sides  of  the  body,  the  points 
should  be  either  transverse  on  both  sides,  or  parallel 
with  the  axis  of  the  limb  on  both  sides.  They  should 
not  be  transverse  on  one  side  and  longitudinal  on  the 
opposite. 

The  various  sensations  may  be  more  acute  than  nor- 
mal— ^hypersesthesia  ;  or  less  acute — anaesthesia ;  or 
there  may  be  a  perceptible  delay  in  their  recognition. 
Occasionally,  when  only  two  points  are  applied  to  the 
skin,  the  patient  will  have  a  sensation  as  if  three  or 
more  touched  him. 

The  vision  may  be  affected  in  several  ways.  There 
may  be  partial  blindness  (amblyopia),  or  there  may  be 
entire  blindness,  or  various  other  changes ; — diplopia,  it 
the  axes  of  the  two  eyes  are  not  parallel.  This  defect 
may  be  present  only  when  the  patient  looks  in  cer- 
tain directions,  if  one  muscle  is  weaker  than  the  cor- 
responding muscle  on  the  opposite  side,  so  that  the 
diplopia  may  not  be  noticed  unless  the  patient  looks  to 
the  right  or  left,  or  upward  or  downward.  Vision  may 
be  limited  in  extent,  so  that  the  patient  sees  only  ob- 
jects placed  directly  in  front  of  him.  Or,  more  rarely, 
central  vision  may  be  wanting,  and  only  objects  around 
the  periphery  of  the  field  of  vision  may  be  recognized. 

The  extent  of  vision  for  white  light  may  be  normal, 
or  nearly  normal,  but  the  field  of  vision  may  be  circum- 
scribed for  colors. 

The  extent  at  which  colors  can  be  seen  is  naturally 
not  so  great  as  the  extent  at  which  white  can  be  seen  ; 
thus,  the  field  of  vision  for  green  is  the  most  contracted, 
next  in  extent  is  the  field  for  red,  then  blue,  then  yel- 


4  A   TREATISE  ON  NERVOUS  DISEASES. 

low.  In  some  cases,  the  field  of  vision,  instead  of  be- 
ing limited  concentrically,  is  lost  on  one  side,  so  that 
the  patient  sees  only  that  part  of  an  object  which  is  to 
the  right  or  left  of  the  median  line.  This  is  called  7ie- 
miopia,  as  referred  to  the  retina,  or  hemianopsia,  as 
referred  to  the  field  of  vision. 

If  accuracy  is  required  in  an  examination,  it  is  ne- 
cessary to  use  a  blackboard  with  a  point  of  fixation, 
the  patient  being  placed  at  a  distance  of  a  foot  from 
that  point,  with  one  eye  covered  ;  a  bit  of  white  paper 
or  chalk  is  then  moved  from  the  outside  inward  until 
the  patient  can  see  it,  and  a  mark  is  made  on  the  board. 
This  is  repeated  at  short  intervals  around  the  central 
spot  until  we  have  mapped  out  roughly  the  field  of 
vision  of  the  eye. 

It  is  generally  sufficient,  however,  with  the  patient 
sitting  in  front  of  the  physician,  with  one  eye  covered, 
the  other  eye  fixed  upon  the  center  of  the  physician's 
face,  for  the  physician  to  move  his  fingers  first  one  side 
and  then  the  other,  above  and  below,  and  inquire 
whether  the  patient  sees  the  motion  of  the  fingers. 
Sometimes  the  field  of  vision  for  white  is  natural,  or 
nearly  natural,  but  colors  can  be  recognized  only  in  one 
lateral  half  of  the  field  of  vision — ^hemianacropia ;  for 
testing  such  a  change,  the  blackboard,  with  bits  of 
colored  paper,  would  be  necessary. 

The  ophthalmoscope  is  absolutely  necessary  in 
order  for  a  satisfactory  examination  of  patients  with 
diseases  either  of  the  brain  or  of  the  spinal  cord,  and  it 
is  better  to  use  it  in  every  case,  no  matter  what  the  dis- 
ease may  be  supposed  to  be. 

To  give  any  satisfactory  description  of  the  use  of 
the  ophthalmoscope  would  require  altogether  too  much 
space,  a  short  description  being  very  unsatisfactory. 
It  is  better  to  refer  to  books  on  ophthalmology  for  such 
description. 

It  is  very  necessary  to  examine  the  pupils,  to  note 
changes  in  their  reaction  to  light  and  to  accommoda- 


GENERAL  INTRODUCTION.  5 

tion,  to  notice  whether  both  pupils  act  alike,  or  whether 
there  are  differences  between  the  two.  In  examining 
the  pupils,  it  is  necessary  to  cover  the  one  not  under 
observation,  as  otherwise  the  light,  falling  upon  the 
sound  eye,  may  cause  contraction,  when,  if  examined 
separately,  the  pujDil  would  remain  immovable. 

METHODS  OF  TESTING  MOTION. 

The  motor  power  may  be  examined  by  simply 
watching  the  movements  of  the  patient.  With  chil- 
dren, it  is  a  good  plan  to  allow  them  to  roam  about  the 
room,  playing  with  whatever  attracts  their  fancy. 

With  adults,  one  can  watch  their  gait  as  they  enter 
the  room,  their  manner  of  taking  a  seat  or  executing 
other  motions ;  if  it  is  necessary  for  them  to  undress, 
the  way  in  which  they  take  off  their  clothing  should  be 
noted.  Much  can  be  learned  by  thus  carefully  watch- 
ing the  ordinary  motions  of  patients. 

If  it  is  desired  to  recognize  clearly  slight  losses  of 
power  in  the  limbs,  the  dynamometer  may  be  used. 
There  are  several  different  forms  of  this  instrument ; 
the  simplest  is  the  best.  It  is  not  necessary  to  estimate 
the  exact  power,  in  pounds,  of  pressure,  but  it  should 
be  possible,  from  the  scale  of  the  dynamometer,  to  esti- 
mate the  relative  power  of  the  two  sides  of  the  body. 
A  rough  idea  of  the  relative  strength  of  the  two  hands 
can  be  gained  by  allowing  the  patient  to  squeeze  one's 
hand. 

Slight  fibrillary  twitchings  of  the  muscles  may 
sometimes  be  excited,  if  they  do  not  occur  spontane- 
ously, by  snapping  the  muscles  with  the  finger.  The 
natural  tone  of  the  muscle  is  also  indicated  by  the 
energy  with  which  a  single  contraction  takes  place 
under  the  snapping  of  the  finger. 

The  most  delicate  test  of  muscular  power  is  elec- 
tricity. Under  some  circumstances  the  muscle  loses  its 
power  of  responding  to  the  irritation  of  the  faradic  or 


6  A    TREATISE  ON  NERVOUS  DISEASES. 

the  galvanic  cnrrent.  Any  muscle  wMch  is  separated 
from  its  centers  of  nutrition  in  the  spinal  cord  under- 
goes the  above  change  of  reaction,  whether  the  disease 
is  a  destruction  of  those  trophic  centers  or  of  the  nerve- 
fibers  passing  from  them  to  the  muscle. 

The  first  change  noticed  in  the  muscle  may  be  a 
slight  and  temporary  increase  of  irritability  for  both 
forms  of  electricity.  A  day  or  two  afterward  the  mus- 
cle begins  to  lose  its  power  of  reacting  to  the  faradic 
current.  By  the  end  of  the  second  or  third  week  it  no 
longer  responds  to  this  stimulus.  After  a  slight  dimi- 
nution of  reaction  to  the  galvanic  current,  during  the 
second  week  the  irritability  of  the  muscle  for  this  cur- 
rent increases  until  it  becomes  much  greater  than  nor- 
mal. This  increased  irritability  for  the  galvanic  cur- 
rent may  continue  for  many  weeks  or  months,  but  at 
length  is  gradually  lost,  until,  if  the  paralysis  is  perma- 
nent, the  muscle  responds  to  neither  current. 

With  this  change  in  the  amount  of  irritability  there 
occurs  a  difEerence  in  the  manner  in  which  the  muscle 
reacts  to  the  galvanic  current.  Instead  of  the  natural, 
rapid,  spasmodic  contraction,  the  muscle  contracts 
slowly,  the  contraction  reaching  its  height  only  after 
a  perceptible  interval  of  time,  and  then  slowly  relax- 
ing— a  change  that  is  very  evident,  even  to, the  un- 
skilled observer. 

There  are  also  changes  in  the  quality  of  the  reaction 
to  the  galvanic  current,  according  as  the  positive  or 
negative  pole  is  placed  upon  the  muscle,  and  the  cur- 
rent closed  or  opened.  These  changes  are  of  less  prac- 
tical value,  and  can  be  learned  from  works  on  electro- 
therapeutics. 

This  '"^reaction  of  degeneration''''  is  of  great  im- 
portance in  diagnosis. 

Reflex  actions  play  an  important  role  in  the  internal 
economy  of  the  body,  and  in  its  relation  with  the  ex- 
ternal world. 

An  impression  made  ui:)on  an  afferent  nerve  is  car- 


GENERAL  INTRODUCTION.  7 

ried  to  a  group  of  nerve-cells  ;  by  means  of  these,  alone 
or  in  connection  with  other  groups,  it  is  transformed 
into  a  motor  impulse,  which  is  carried  by  efferent 
nerves  to  muscles,  and  causes  them  to  contract.  This 
is  the  simplest  form  of  a  reflex  action.  The  muscles 
excited  are  usually  those  nearest  the  point  receiving 
the  irritation.  K,  however,  the  irritation  is  severe,  dis- 
tant muscles  may  be  brought  into  action,  even  those  on 
the  opposite  side.  The  muscles  may  not  be  voluntary ; 
they  may  belong  to  internal  organs,  as  stomach,  intes- 
tines, bladder ;  the  impression  may  be  made  upon  these 
viscera,  not  on  the  surface  of  the  body ;  the  groups  of 
nerve-cells  may  not  be  in  brain  or  cord,  but  in  one  of 
the  symiDathetic  ganglia,  or  in  the  walls  of  the  viscus. 

The  impressions  upon  the  special  senses  may  give 
rise  to  reflex  actions  confined  to  the  organ  receiving  the 
impression,  as  movements  of  the  iris,  contraction  of 
the  intrinsic  muscles  of  the  ear ;  or  the  impression  may 
be  so  strong  as  to  call  into  action  other  muscles  of  the 
body,  as  when  a  loud  noise  or  bright  flash  causes  the 
head  to  turn,  or  sets  the  heart  beating  violently. 

Reflex  actions  control,  in  a  very  large  degree,  the 
secretions  of  the  different  glands  and  the  supply  of 
blood  to  various  parts  of  the  body. 

Thoughts  and  emotions  have  a  great  influence  upon 
the  circulation,  the  secretions,  and  the  nutrition  of  the 
body ;  this  influence  is  generally  reflex  in  its  nature, 
and  may  often  be  utilized  in  the  treatment  of  disease. 

It  is  not  necessary  that  the  brain  should  take  cogni- 
zance of  the  impressions  which  excite  reflex  action ;  in- 
deed, these  actions  are  often  more  powerful  when  the 
subject  is  unconscious  of  the  impression  exciting  them, 
as  when  the  spinal  cord  is  divided. 

The  reflex  centers  for  the  different  groups  of  mus- 
cles in  the  limbs  are  situated  at  about  the  level  whence 
the  nerves  supx^lying  those  muscles  arise.  There  are 
reflex  actions  which  follow  an  irritation  of  the  skin — 
cutaneous  reflexes  :  also  actions  which  follow  irritation 


8  A    TREATISE  ON  KERVOUS  DISEASES. 

of  deej^er  parts,  of  wMcli  the  tendon  reflexes  are  ex- 
amples. 

The  various  reflexes  reqnire  a  separate  descriptiono 
Gowers  has  given  the  clearest  account  of  these.  By 
gently  irritating  the  skin,  by  tickling,  scratching,  or 
pricking,  the  superficial  or  cutaneous  reflexes  may  Ibe 
excited.  Gowers  mentions  the  plantar  (from  the  sole 
of  the  foot),  depending  on  the  lower  part  of  the  lumbar 
enlargement ;  the  gluteal,  by  irritating  the  skin  of  the 
buttocks,  depending  on  the  cord  at  the  level  of  the 
fourth  or  fifth  lumbar  nerve  ;  the  cremaster,  by  which 
the  testicle  is  drawn  up  when  the  skin  on  the  inner 
aspect  of  the  thigh  is  irritated,  depending  on  the  first 
and  second  lumbar  pairs  ;  the  abdominal,  by  irritating 
the  skin  at  the  side  from  the  ribs  downward,  depending 
upon  the  eighth  to  the  twelfth  dorsal  nerves  ;  the  epi- 
gastric, produced  by  irritating  the  side  of  the  chest  in 
the  fourth  to  the  sixth  intercostal  spaces,  depending 
upon  the  fourth  to  the  seventh  dorsal  nerves.  There 
are  sometimes  reflexes  on  the  back,  caused  by  irritating 
the  skin  along  the  edge  of  the  erector-spinse  muscles  ; 
and  when  the  skin  between  the  scapulae  is  irritated, 
some  of  the  scapular  muscles  contract,  the  scapular 
reflex. 

The  deep  reflexes,  as  they  are  sometimes  called,  in- 
clude the  clonus  and  tendon  reflexes.  The  more  com- 
mon are  the  patella  tendon  reflex.,  and  that  developed 
just  above  the  elbow.  To  obtain  these,  the  limb  should 
be  semi-flexed,  should  hang  free  without  voluntary 
muscular  tension  ;  a  sharp  blow  just  below  the  patella, 
on  its  ligament,  or  on  the  tendon  just  above  the  olec- 
ranon process,  produces  a  sudden  contraction  of  the 
muscle  and  partial  extension  of  the  limb.  To  examine 
for  the  patellar  tendon  reflex,  the  patient  should  sit  on 
a  high  chair  or  table,  with  the  legs  swinging  free  ;  or, 
if  the  feet  rest  on  the  floor,  one  leg  may  be  thrown  over 
the  opposite  knee,  or  the  physician  can  pass  his  arm 
under  the  knee,  resting  his  hand  on  the  other  knee,  the 


GENERAL  INTRODUCTION.  9 

leg  lianging  free  over  his  arm.  For  tlie  examination 
of  the  triceps  humeri  tendon  reflex,  the  patient's  arm, 
semi-flexed,  should  be  supported  so  that  the  forearm 
can  move  with  moderate  freedom.  Tendon  reflexes  are 
occasionally  found  with  other  tendons. 

Ankle-clonus  is  excited  by  holding  the  patient's  leg 
extended,  or  very  slightly  flexed  on  the  thigh  ;  then,  by 
suddenly  flexing  the  foot,  and  perhaps  the  toes  too, 
the  Achilles  tendon  and  the  flexors  of  the  toes  are  put 
on  the  stretch  ;  then  a  rhythmic  contraction  and  relaxa- 
tion of  the  calf  muscles  occur,  which  continue  as  long 
as  the  proper  degree  of  flexion  of  the  foot  is  maintained. 
Sometimes  a  strong  pressure  on  the  sole  of  the  foot  is 
needed  to  develop  this,  and  sometimes  only  a  very  light 
pressure,  the  stronger  checking  the  clonus.  The  clonus 
can  sometimes  be  excited  by  a  similar  flexion  of  the 
wrist-joint.  When  the  reflex  excitability  is  much  ex- 
aggerated, it  may  be  possible  to  obtain  a  clonus  in  the 
toes  or  fingers. 

The  front  tap  contraction.,  which  Gowers  says  is  a 
very  delicate  test  of  increased  irritability,  is  obtained 
by  keeping  the  leg  nearly  extended  on  the  thigh,  the 
foot  moderately  flexed  so  as  to  keep  the  tendo- Achilles 
slightly  tense,  then  a  gentle  tap  with  the  ends  of  the 
fingers  is  made  over  the  edge  of  the  tibia.  The  calf 
muscles  contract,  drawing  the  foot  down ;  the  action  is 
usually  very  slight,  and  is  the  stronger  the  nearer  the 
ankle  the  tap. 

A  tap  over  the  head  of  the  tibia  will  sometimes  pro- 
duce a  contraction  of  the  rectus  f  emoris  ;  or  a  tap  over 
the  radius  at  the  wrist  will  cause  contraction  of  the 
biceps  ;  over  the  ulnar  at  the  wrist,  of  the  triceps. 

Tdcfie  cerebrate  is  developed  by  drawing  the  finger- 
nail or  the  finger  across  the  skin,  especially  over  the 
abdomen.  A  red  line  appears  after  a  variable  length 
of  time,  corresponding  to  the  tract  of  irritation.  This 
line  can  be  produced  in  a  large  majority  of  patients. 


10  A   TREATISE  ON  NERVOUS  DISEASES. 

It  is  of  value  as  a  symjDtom  only  when  it  appears  very 
quickly  and  is  of  a  deep  color ;  the  line  made  with  the 
nail  is  brighter  than  the  broader  line  made  with  the 
finger.  At  the  side  of  the  red  line  the  skin  seems  to 
acquire  a  paler  tint,  as  if  the  smaller  vessels  were  con- 
tracted. This  sign  is  of  less  value  than  was  formerly 
supposed. 

CTieyne- Stokes  respiration.,  named  from  those  who 
first  described  it,  consists  of  a  peculiar  rhythmical 
change  in  the  breathing.  After  a  pause,  in  which  two 
or  three  respirations  are  lost,  the  lungs  are  again  filled, 
the  breathing  slowly  increases  in  rapidity  until  a  limit 
is  reached  ;  the  frequency  then  diminishes  until  there  is 
another  pause.  This  succession  of  respiratory  acts  is 
then  repeated.  This  symptom  is  a  very  serious  one, 
and  almost  always  indicates  a  fatal  termination. 

Bed-sores  form  with  extreme  rapidity  in  some  cases 
of  lesion  of  the  spinal  cord,  as  the  result  of  irritation 
of  the  cord ;  at  other  times  they  are  slow  in  appear- 
ance. They  are  among  the  most  annoying  complica- 
tions, and  sometimes  give  great  discomfort. 

Perfect  cleanliness,  bathing  the  skin  after  every 
passage,  changing  the  bedding  when  wet  or  soiled,  are 
absolutely  necessary  to  prevent  their  occurrence.  When 
the  patient  can  be  moved,  his  position  should  be  changed 
to  relieve  pressure.  The  whole  back,  especially  the 
sacral  region,  should  be  bathed  daily  with  strong  al- 
cohol. 

When  the  skin  becomes  discolored  and  a  bed-sore 
seems  imminent,  even  greater  care  should  be  taken  in 
bathing,  that  spot  be  relieved  from  pressure,  and,  if  the 
skin  is  broken,  zinc  ointment  may  be  used.  Further 
mischief  may  sometimes  be  thus  avoided.  If  a  slough 
forms,  the  best  treatment  is  the  alternate  use  of  ice  and 
poultices — ice  for  two  or  three  minutes,  then  poultice 
for  two  or  three  hours.  Of  course,  the  offensive  dis- 
charges must  be  removed  ;  where  the  edges  are  under- 
mined, a  gentle  stream  of  water  from  a  fountain  syringe 


GENERAL  INTRODUCTION.  11 

must  be  used  to  wash  out  the  pockets  holding  the  dis- 
charge. Carbolic  acid,  thymol,  phenol,  or  similar  sub- 
stances, may  be  sprinkled  on  the  poultices.  A  char- 
coal poultice  is  sometimes  of  benefit. 

Various  water-beds,  air-beds,  and  fracture-beds  are 
in  use  for  these  cases,  and  may  answer  a  good  end. 

A  mild  galvanic  current  has  been  recommended, 
obtained  by  a  silver  plate  on  the  sore,  connected  by 
wire  with  a  zinc  plate  over  the  sound  skin,  and  a  piece 
of  wet  cloth  placed  between  the  zinc  and  the  skin. 

Constipation  accompanies  many  nervous  affections, 
whether  organic  or  functional.  Violent  means  to  reme- 
dy this  are  rarely  desirable.  Hyoscyamus,  belladonna, 
nux  vomica,  can  be  added  to  prescriptions  or  given  in- 
dependently, and  may  relieve  the  bowels  sufficiently. 
If  these  are  not  sufficient,  small  doses  of  (impound 
extract  of  colocynth  may  be  added.  Unless  there  is 
some  contra-indication  for  strychnia,  the  following  may 
prove  serviceable : 


^ 

Ext.  colocynth.  comp.. 

.  gr. 

|to2; 

Ext.  belladonnse, 

gr. 

itoi; 

Ext.  nucis  vomic, 

gr. 

itoi 

M. 

Fl.  pil. 

A  half -grain  or  grain  of  ipecac  may  be  added  to  this 
with  advantage  if  there  is  slight  gastric  disturbance. 
This  should  be  given  from  once  to  three  times  daily,  as 
may  be  necessary. 

Drinking  copiously,  especially  a  large  supply  of 
water,  hot  or  cold,  early  in  the  morning,  will  many 
times  be  all  that  is  necessary. 

In  lesions  of  the  spinal  cord,  more  energetic  cathar- 
tics may  be  needed ;  aloin  or  podophyllin,  with  bella- 
donna or  hyoscyamus,  can  be  given  in  small  pills.  Ex- 
tract of  colocynth  may  be  combined  with  these.  Ene- 
mata  of  soap-suds  or  castor-oil,  or  both,  may  be  needed 
to  assist  the  drugs.  It  is  very  desirable  to  avoid  im- 
paction of  the  faeces. 


12  A   TREATISE  ON  NERVOUS  DISEASES. 

If  a  stool  has  been  long  delayed,  an  enema  of  six  to 
sixteen  ounces  of  olive-oil,  retained  two  or  three  hours, 
then  followed  by  a  pint  or  more  of  soap-suds,  will  often 
produce  a  motion  with  comparatively  little  discomfort 
to  the  patient.  Of  course,  the  physician  should  judge  of 
the  size  of  the  enemata  by  the  condition  of  the  patient. 
A  "  fountain  syringe  "  is  much  preferable  to  others. 

Cystitis  is  frequently  a  troublesome  complication 
in  cases  of  paralysis.  It  is  most  frequently  associated 
with  lesions  of  the  spinal  cord,  and  sometimes  is  rather 
early  in  its  appearance.  Whenever  there  is  retention 
of  urine,  there  is  danger  lest,  being  only  partially  evacu- 
ated, the  residue  should  become  alkaline,  and  phos- 
phatic  sediments  form ;  the  decomposed  urine  is  a 
source  of  irritation,  and  inflammation  of  the  bladder  is 
set  uj) ;  this  inflammation  may  extend  to  the  ureters 
and  kidneys,  giving  rise  to  much  distress,  and  being 
itself  a  source  of  exhaustion  and  danger. 

The  bladder  should  be  emptied  by  catheter  twice  a 
day.  A  long  rubber  tube  attached  to  the  end  of  the 
catheter,  hanging  into  a  vessel  on  the  floor  by  the  side  of 
the  bed,  helps  to  keep  the  bed  dry,  and  acts  as  a  siphon 
to  more  thoroughly  empty  the  bladder.  If  the  urine 
becomes  alkaline,  benzoic  acid,  five  grains  thrice  daily, 
or  boracic  acid,  or  salicylic  acid,  may  be  given.  The 
bladder  should  be  washed  out  at  least  once  a  day  with 
a  double  catheter,  using  a  weak  solution  of  carbolic  acid 
or  nitrate  of  silver ;  the  latter  can  be  used  of  a  strength 
of  three  or  four  grains  to  the  ounce  every  third  to  sixth 
day. 

The  diet  should  be  easily  digestible  with  mild 
drinks. 

The  nutrition  of  patients  is  often  below  normal.  It 
is  a  task  to  eat  when  there  is  no  appetite,  and  the  pa- 
tient, yielding  to  his  aversion  for  food,  eats  little  ;  grad- 
ually the  whole  system  suffers,  yet  there  is  no  demand 
for  more  food  ;  the  system  becomes  accustomed  to  the 
lowered  standard  of  nourishment. 


GENERAL  INTRODUCTION.  13 

Many  times  tlie  greatest  patience  and  tact  is  needed 
to  restore  the  lost  strength.  It  is  generally  better  to 
give  food  frequently  in  small  quantities  than  to  try  to 
increase  the  amount  taken  at  one  time.  The  intervals 
may  be  as  near  as  every  half -hour  or  hour. 

Milk  is  the  most  convenient  food.  It  can  be  made 
more  palatable  by  adding  salt,  and  more  digestible  by 
adding  lime-water,  half  an  ounce  to  six  ounces  of  milk, 
or  five  grains  of  bicarbonate  potassa  or  soda  to  the  same 
amount.  It  should  be  slowly  sipped,  or  taken  with  a 
teaspoon — not  drank :  one  to  three  quarts  a  day,  ac- 
cording to  how  much  else  is  taken.  Koumiss  is  a  pleas- 
ant and  easily  digestible  form  of  milk  ;  directions  for 
making  it  are  given  in  the  Dispensatory. 

Eggs,  if  perfectly  fresh,  are  usually  acceptable  pre- 
pared in  various  ways.  It  is  very  hard  to  obtain  per- 
fectly fresh  eggs  in  a  city ;  most  city  eggs  are  some- 
what stale,  and  sometimes,  if  eggs  are  laid  in  musty 
hay,  they  acquire  a  disagreeable  flavor ;  in  either  case 
patients  may  not  be  able  to  enjoy  them.  Eggs  should 
not  be  fried. 

Fat  is  an  important  article  of  diet  for  nervous  pa- 
tients. Often  too  little  is  taken.  God-liver  oil  is  ex- 
cellent if  it  can  be  taken;  if  not,  cream  and  butter  may 
be  used  as  substitutes. 

Butter  should  not  be  heated  above  the  boiling-point 
for  water,  and  should  not  he  used  for  cooJcing. 

A  powder  of  beef,  which  is  made  by  J.  Fere,  im- 
ported by  E.  Fougera  &  Co.,  New  York,  forms  a  valu- 
able article  of  diet  in  many  cases.  It  can  be  mixed 
with  water  or  milk  ;  it  is  already  cooked.  The  ordinary 
beef -teas  and  essences  are  of  very  small  value  as  food. 

Sometimes  it  may  be  necessary  to  feed  with  a  stom- 
ach-tube. This  may  be  passed  twice  or  even  three 
times  a  day,  and  it  is  much  better  to  use  it  than  to 
have  a  patient  live  half  starved.  In  hysteria  and  in- 
sanity it  is  sometimes  absolutely  necessary  to  thus  feed 
a  patient. 


14  A   TREATISE  ON  NERVOUS  DISEASES 

When  there  is  obstinate  vomiting,  it  may  be  well  to 
let  the  stomach  rest  a  few  days,  giving  only  small  pieces 
of  ice  ;  then  begin  with  small  amounts  of  food,  gradu- 
ally increasing. 

Patients  may  be  fed  by  the  rectum,  using  partially 
digested  meat,  milk,  or,  better  than  these,  an  egg  beaten 
up  with  ten  grains  of  pepsin.  Generally  an  egg  or  two 
can  be  given  in  this  way  every  five  or  six  hours ;  it  is 
better  to  wash  out  the  bowels  once  in  twenty-four  to 
forty-eight  hours  with  a  warm- water  enema.  Nutrient 
enemata  should  have  a  temperature  of  about  95°  to  100°. 
If  not  too  much  exhausted  at  first,  patients  can  be 
sustained  for  a  fortnight  or  more  in  this  way. 


DISEASES  OF  THE  BRAIN. 


CHAPTER  II. 

IlSrTRODUCTOEY. 

Anatomy.— Henle,  J.,  Handbuch.  der  Nervenlehre  des  Men- 
schen. — Wernicke,  C,  Lehrbuch  der  Gebimkrankheiten,  Bd.  I. 
— ScHWALBE,  G.,  Lehrbuch.  der  Neurologie  (HofPmann's  Lehrbuch 
der  Anatomie  des  Menschen,  2.  Bd.,  2.  Abt.). — Ranney,  A.  L.,  The 
Applied  Anatomy  of  the  Nervous  System. — Eckee,  A.,  The  Cere- 
bral Convolutions  of  Man.  Trans,  by  Robert  T.  Edes.  1873. — 
DuRET,  H.,  Recherches  anatomiques  sur  la  circulation  de  I'en- 
cephale.  Arch,  dephysiol.,  normal  etpathol.,  1874. — Duval,  M., 
Recherches  sur  I'origine  reelle  des  nerfs  craniens.  J.  de  Vanat. 
et  de  laphysiol.,  xii-xvi.,  1876-80. 

Physiology.— Fritsch  und  Hitzig,  Ueber  die  electrische  Erreg- 
barkeit  des  Grosshirns.  Reichart  und  Du  Bois-Rey mend's 
Arch.,  1870.  —  Ferrier,  Experimental  Researches  in  Cerebral 
Physiology  and  Pathology.  West  Riding  Asylum  Med.  Rep., 
1873.— Ibid.,  The  Functions  of  the  Brain.  1876.— Ibid.,  The  Lo- 
calization of  Cerebral  Disease.  New  York,  1879. — Charcot,  J.  M., 
Lectures  on  Localization  in  Diseases  of  the  Brain.  Trans,  by  E.  P. 
Fowler.  New  York,  1878.— Carville,  C,  and  Duret,  H.,  Sur 
les  functions  des  hemispheres  cerebraux.  Arch,  de  physiol., 
1875.— DODDS,  W.  J.,  On  the  Localization  of  the  Functions  of  the 
Brain  :  being  an  Historical  and  Critical  Analysis  of  the  Question. 
Jour,  of  Anat.  and  Physiol.,  1878. — Seguijst,  E.  C,  Lectures  on 
the  Localization  of  Spinal  and  Cerebral  Disease.  N.  Y.  Med. 
Record,  1878. — Pitres,  J.  A.,  Recherches  sur  les  lesions  du  cen^ 
tre  ovale  des  hemispheres  cerebraux,  etudiees  au  point  de  vue  des 
localisations  cerebrales.  Versailles,  1877. — Exner,  Sigmund,  Un- 
tersuchungen  uber  die  Localisation  der  Functionen  in  der  Gross- 
hirnrinde  des  Menschen.  Wien,  1881. — MuNK,  Hermann,  Ueber 
die  Functionen  der  Grosshirnrinde.  Berlin,  1881.— Fere,  Ch., 
Contribution  a  I'etude  des  troubles  fonctionelles  de  la  vision  par 
lesions  cerebrales.  Paris,  1882. — Wadsworth,  O.  F.,  Three  Cases 
of  Homonymous  Hemianopia.  Boston  Med.  and  Surg.  Jour., 
May  22, 1884,  p.  483. — Wilbrand,  H.,  Ueber  Hemianopsie  und  ihr 
Verhaltniss  zur  topischen  Diagnose  der  Gehirnkrankheiten.  Ber- 
lin, 1881. — Ibid.,  Ophthalmiatrische  Beitrage  zur  Diagnostik  der 
Gehirnkrankheiten.  Wiesbaden,  1884. 
2 


18 


DISEASES  OF  TEE  BEAIN. 


ANATOMY. 


The  accompanying  diagrams  from  Ecker,  with  ex- 
planations, will  illustrate  better  than  any  verbal  de- 
scription the  nomenclature  of  the  convolutions. 


Fig.  1. — View  of  brain  from  the  side.     (Ecker.) 

F,  frontal  lobe ;  P,  parietal  lobe  ;  <?,  occipital  lobe  ;  T,  temporal  lobe  ;  8,  fis- 
sura  Sylvii ;  S\  horizontal,  S'\  ascending  branch ;  c,  sulcus  centralis,  fissure  of 
Eolando ;  A,  anterior  central  convolution,  ascending  frontal  convolution ;  B,  pos- 
terior central  convolution,  ascending  parietal  convolution ;  i^i,  upper  (or  first), 
i^2,  middle  (or  second),  i^g,  lower  (or  third)  frontal  convolution.  (Occasionally 
these  are  numbered  from  below  upward.  The  above  is  the  more  generally  received 
nomenclature.)  /i,  upper, /a,  lower, /g,  vertical  (praecentral)  frontal  fissure;  Pi, 
upper,  Pi)  lower  parietal  lobule ;  Pj,  gyrus  supramarginalis  (5'  is  on  the  same 
gyrus) ;  Pj',  gyrus  angularis.  (This  passes  around  the  posterior  end  of  the  first 
temporal  fissure,  uniting  the  first  temporal  and  supramarginal  convolutions  with 
the  second  temporal  convolution.)  ip,  sulcus  interparietalis ;  cm,  end  of  the  sul- 
cus calloso-marginalis ;  <9i,  first,  Oi,  second,  6*3,  third  occipital  convolution;  po, 
fissura  parieto-occipital,  internal  perpendicular  fissure ;  0,  sulcus  occipitalis  trans- 
versus;  02,  sulcus  occipitalis  longitudinalis  inferior ;  T'l,  first,  T'g,  second,  T's,  thii'd 
temporal  convolution  ;  ^1,  first,  ^2,  second  temporal  fissure,  {t^  is  generally  bridged, 
and  so  interrupted.) 


ANATOMK 


19 


In  these  diagrams  only  the  important  sulci  are  given ; 
these  vary  somewhat  in  different  brains ;  the  convolu- 
tions between  these  sulci  are  subdivided  by  secondary 
sulci,  whose  arrangement  is  less  constant.  Occasion- 
ally one  of  the  principal  sulci  may  be  bridged  over  by 
a  convolution,,  causing  an  apparent  irregularity. 


Fig.  2. — View  of  the  brain  from  above.     (Ecker!) 
Lettering  same  as  in  Fig.  1. 


From  the  cortex,  medullary  nerve-fibers  pass  through 
the  white  substance,  the  centrum  ovale,  converging  to- 
ward the  basal  ganglia — corona  radiata.  They  con- 
verge from  all  parts  toward  a  tract  of  white  substance 


20 


DISEASES  OF  THE  BRAIN. 


which  separates  these  basal  ganglia  from  each  other — 
the  internal  capsule. 

This  capsule  is  one  of  the  regions  whose  physiology 
is  best  known,  whose  lesion  gives  the  most  definite 
and  permanent  symptoms. 


Fig.  3. — ^View  of  the  brain  from  below.     (Eckee.) 

-^1)  gy™s  rectus,  the  prolongation  of  the  first  frontal  convolution  ;  i^j,  middle, 
7^3,  lower  frontal  convolution ;  fi,  sulcus  olfactorius ;  f^^  sulcus  orbitalis ;  Tj, 
second,  or  middle,  T3,  third,  or  lower  temporal  convolution ;  Ti,  gyrus  occipito- 
temporalis  lateralis  (lobulus  fusiformis),  7*6,  gyrus  occipito-temporalis  medialis 
(lobulus  lingualis) ;  ^2,  middle,  1^3,  lower  temporal  fissure ;  t^,  sulcus  occipito-tem- 
poralis inferior ;  po,  fissura  pari eto- occipitalis ;  oc,  fissura  calcarina ;  H^  gyrus 
hippocampi;  ZT",  gyrus  uncinatus ;  CA,  chiasma;  cc,  corpora  albicantia;  KK, 
pedunculi  cerebri ;  C,  corpus  callosum. 


AIIATOMY. 


21 


A    c 


;    B 


--0 


— D 


Fig.  4. — View  of  the  medial  surface  of  the  right  hemisphere.     (Eckek.) 

CO,  corpus  callosum,  cut  through  the  middle ;  Gf,  gyrus  fomicatus,  ff,  gyrus 
hippocampi,  h,  sulcus  hippocampi,  U,  gyrus  uncinatus  ;  cm,  sulcus  calloso-margi- 
nalis,  Fi,  first  frontal  convolution,  its  medial  side ;  c,  end  of  sulcus  centralis,  A, 
anterior,  £,  posterior  central  convolution ;  Oz,  cuneus ;  P',  prsecuneus  ;  po,  fissura 
parieto-occipitahs ;  o,  sulcus  occipitalis  transversus ;  oc,  fissura  calearina ;  oc', 
upper,  oc",  lower  branch ;  D,  gyrus  descendens ;  T^,  gyrus  occipito-temporalis 
lateralis;  T's,-  gyrus  occipito-temporalis  medialis  (lobulus  lingualis);  around  the 
centra]  fissure  is  a  quadrilateral  lobule.  A,  -5,  called  the  paracentral  lobule. 


The  accompanying  representation,  an  outline  from 
a  photograpli  by  Bitot,  will  give  a  sufficiently  clear  idea 
of  the  more  important  divisions. 

The  caudate  nucleus  and  the  outer  or  third  member 
of  the  lenticular  nucleus  receive  few  fibers  from  the  co- 
rona radiata,  nearly  all  of  whose  fibers  pass  into  the  in- 
ternal capsule.  Fine  bundles  of  white  fibers  pass  from 
the  lenticular  nucleus  into  the  internal  capsule,  and 
seem  to  pass  on  to  the  pyramidal  tract.  From  the 
caudate  nucleus  many  bundles  of  fibers  pass  into  the 
anterior  limb  of  the  internal  capsule  ;  others  cross  this 
and  enter  the  lenticular  nucleus. 


22 


DISEASES  OF  TEE  BBAIK 


The  fibers  which  have  been  described  as  entering  the 
internal  capsule  are  destined  in  part  for  the  basis  of 
the  crus ;  the  remainder  are  lost  in  the  different  parts 
of  the  optic  thalamns,  and  in  the  tegmentum  cruris, 
some  reaching  the  cerebellum. 


Fig.  5. — Horizontal  section  of  the  brain. 

ccl^  corpus  callosum ;  c»,  caudate  nucleus ;  fv,  fifth  ventricle ;  cZ,  claustrum ;  i, 
island  of  Eeil ;  cf^  crura  of  the  fornix,  which,  turning  upon  themselves,  form  the 
corpora  albicantia ;  ec,  external  capsule ;  tv^  third  ventricl'e  ;  tTi,  optic  thalamus ; 
cge,  external  corpus  geniculatum ;  cn\  the  lower  part  of  caudate  nucle^os ;  pv^  pul- 
vinar  ;  cq,  corpora  quadrigemina  ;  cgi^  internal  corpus  geniculatum ;  i,  ii,  iii,  the 
three  divisions  of  lenticular  nucleus  (on  the  left  only  two  divisions  are  seen) ;  aic, 
Mc,  pic,  the  anterior  limb,  knee,  and  posterior  limb  of  the  internal  capsule. 


The  following  diagrams,  in  some  respects  slightly 
modified  from  Wernicke,  will  help  to  an  understand- 
ing of  the  course  of  the  most  important  bundles  of 
fibers,  and  the  relations  of  the  ganglia. 


ANATOMY. 


23 


Charcot  lias  shown  that  only  a  part  of  the  fibers  of 
the  internal  capsule  passes  beyond  the  pons.  The  cap- 
sule is  divided  into  an  anterior  and  a  posterior  limb, 
the  angle  formed  by  the  two  being  called  the  knee  of 


Fig.  6. — Diagram  of  a  perpendicular  section  of  the  brain,  showing  the  internal 
capsule  and  its  relations. 

gf,  gyrus  fornicatas ;  cc,  corpus  callosum ;  v,  ventricle ;  /,  fornix  ;  nc,  caudate 
nucleus ;  th,  optic  thalamus  ;  ci,  internal  capsule,  upper  (anterior)  limb ;  ^,  pedun- 
cle ;  ci\  internal  capsule,  lower  (posterior)  limb  ;  nc'.,  lower  part  of  caudate  nucleus  J 
0,  optic  tract ;  gh,  gyrus  hippocampus ;  i,  island  of  Keil ;  d,  claustrum ;  nl,  len- 
ticular nucleus. 


the  capsule.  The  fibers  from  the  anterior  limb  pass 
through  the  inner  portion  of  the  basis  cruris.  When 
a  lesion  implicates  only  these,  the  descending  degener- 


24 


DISEASES  OF  THE  BRAIN. 


ation  can  be  traced  as  far  as  the  pons,,  but  not  beyond. 
That  portion  of  the  fibers  of  the  basis  which  arises  from 


Fig.  7. — Diagram  of  a  horizontal  section  of  the  brain,  showing  the  course  of  the 
peduncular  fibers. 

ca,  anterior  commissure  ;  i,  ii,  in,  the  three  divisions  of  lenticular  nucleus ;  pi, 
pm^  pe,  the  internal,  middle,  and  external  portions  of  the  pedimcular  fibers  passing 
below  the  optic  thalamus.    Other  letters  as  in  Fig.  5. 


ANATOMY. 


25 


the  inner  two  thirds  of  the  posterior  limb  passes 
through  the  middle  third  of  the  basis,  and  secondary 
degeneration  of  these  fibers  can  be  followed  through 
the  pons  and  medulla  into  the  pyramidal  tracts  of  the 
cord.  In  Fig.  7  this  portion  of  the  internal  capsule  is 
shaded.  Lesion  of  the  outer  third  of  the  posterior 
limb  of  the  capsule  is  followed  by  no  descending  de- 
generation; hence  it  is  supposed  that  its  fibers  are 
centripetal,  and  they  pass  into  the  corona  radiata  of 
the  occipital  lobe. 


Fig.  8. — Diagram  illustrating  decussation  of  optic  nerves  in  the  chiasma,  and 
the  effect  of  lesions  of  portions  of  the  optic  tract. 
0,  optic  nerves;  ot,  optic  tracts;  eg,  corpora  geniculata;  a,  b,  c,  lesions  in 
fi'ont,  at  side  of  chiasma,  and  on  optic  tract. 


26 


DISEASES  OF  THE  BRAIK 


The  decussation  of  the  optic  nerves  at  the  chiasma 
is  only  partial.  The  diagram  on  page  25  may  give  an 
idea  of  the  arrangement  of  the  fibers.  The  fibers  from 
the  right  optic  tract  pass  to  the  right  side  of  both  reti- 
nas, the  larger  portion  decussating  with  those  of  the 
opposite  side  ;  and  mce  mrsa  for  those  of  the  left  optic 
tract. 


Fig.  9. — This  is  modified  from  Huguenin,  to  agree  with  Wernicke's  description 
of  the  origin  of  the  fibers  of  the  optic  tract. 
aq^  anterior  corpus  quadrigeminum  ;  pu^  pulvinar ;  cpq,  crus  of  posterior  corpus 
quadrigeminum ;  cgi,  internal  corpus  geniculatum ;  cge,  external  corpus  genicu- 
latum ;  cr,  posterior  fibers  of  the  corona  radiata,  passing  to  the  occipital  lobe ;  oe, 
external  division  of  the  optic  tract,  passing  to  the  external  corpus  geniculatum,  the 
pulvinar,  and  the  anterior  corpus  quadrigeminum ;  oi,  the  inner  division  of  the 
optic  tract,  passing  to  the  internal  corpus  geniculatum,  and  the  posterior  corpus 
quadrigeminum  ;  p,  peduncular  fibers  ;  p',  the  hemispherical  bundle  seen  in  trans- 
verse section  of  the  crus  cerebri ;  sn,  substantia  nigra ;  iii,  third  nerve ;  iii',  its 
nucleus  ;  scp,  superior  cerebellar  peduncle  (red  nucleus)  ;  plh^  posterior  longitu- 
dinal bundle  ;  as,  aqueduct  of  Sylvius. 


ANATOMY.  27 

When  an  attempt  is  made  to  study  the  optic  tract, 
tracing  its  fibers  to  their  central  origin,  we  meet  some 
opposing  statements  made  by  different  authors.  Wer- 
nicke describes  the  optic  tract,  passing  from  the  chiasma 
backward,  as  dividing  into  two  portions — an  external, 
which  is  much  the  larger,  and  a  smaller  internal ;  the 
former  can  be  traced  to  the  external  corpus  genicula- 
tum,  the  posterior  portion  of  the  optic  thalamus  called 
the  pulvinar,  and  the  anterior  corpus  quadrigeminum ; 
the  internal  portion,  he  says,  arises  from  the  internal 
corpus  geniculatum,  and  the  posterior  corpus  quadri- 
geminum ;  this  division,  he  says  (following  v.  Gudden), 
has  no  connection  with  the  optic  nerve.  A  bundle  of 
fibers  seems  to  pass  directly  from  the  corona  radiata  of 
the  occipital  lobe  to  the  optic  tract. 

The  preceding  diagram.  Fig.  9,  which  follows  Wer- 
nicke, is  modified  from  Huguenin,  and  will  aid  in  un- 
derstanding these  divisions  of  the  optic  tract. 

The  advantage  of  following  the  different  bundles  of 
fibers  through  the  crura  cerebri,  pons,  and  medulla 
would  be,  to  say  the  least,  very  doubtful.  Huguenin, 
Wernicke,  and  Duval  have  given  us  studies  of  this  re- 
gion. A  few  outline  drawings  or  diagrams,  with  brief 
explanation,  will  serve  to  localize  the  important  nerve- 
centers  at  different  levels. 

The  third  nerve  enters  the  crus  near  the  anterior 
border  of  the  pons,  not  far  from  the  median  line,  form- 
ing the  internal  boundary  of  the  pyramidal  fibers.  The 
nerve  splits  up  into  bundles  of  fibers  which  diverge,  the 
inner  bundles  following  a  slightly  waving  course  back- 
ward to  the  nucleus  ;  the  outer  bundles,  forming  a  curve, 
pass  through  the  outer  edge  of  the  cerebellar  peduncu- 
lar fibers  (the  red  nucleus),  then  converge  to  the  nucle- 
us, which  is  situated  on  either  side  of  the  median  line 
just  anterior  to  the  aqueduct  of  Sylvius.  Anterior  to 
the  nucleus  the  nerve  passes  through  the  posterior  lon- 
gitudinal fasciculus.  The  nucleus  of  the  third  is  irregu- 
larly pear-shaped,  the  smaller  end  pointing  forward, 


28 


DISEASES  OF  THE  BRAIK 


lying  near  the  median  raphe.  Curving  around  from 
the  posterior  longitudinal  fasciculus  can  be  seen  the  de- 
scending (motor)  root  of  the  fifth  nerve.  Posterior  to 
these  is  the  anterior  corpus  quadrigeminum,  and  ex- 
ternal to  this  the  internal  corpus  geniculatura. 


Fig.  10. — Origin  of  third  nerve.     (After  Wernicke.) 

cs,  aqueduct  of  Sylvius  ;  plb,  posterior  longitudinal  bundle ;  iii,  third  nerve ; 
III',  its  nucleus ;  p,  basis  of  cms  cerebri  (foot  of  the  peduncle) ;  s«.,  substantia 
nigra ;  cp,  superior  cerebellar  peduncle  (red  nucleus) ;  cgi,  internal  corpus  genicu- 
latum ;  acq^  anterior  corpus  quadrigeminum ;  v,  descending  (motor)  root  of  tri- 
geminus. 


The  fourth  nerve  enters  the  valve  of  Yieussens  just 
behind  the  posterior  corpus  quadrigeminum,  decus- 
sates in  the  valve,  curves  around  the  aqueduct  of  Syl- 
vius, and  enters  its  nucleus,  which  is  situated  just  be- 
hind (below)  the  nucleus  of  the  third  nerve  in  relatively 
the  same  position. 

Both  the  third  and  fourth  nerves  receive  a  few  fibers, 
ascending  from  the  sixth  nerve,  from  the  posterior  lon- 
gitudinal fasciculi,  which  do  not  enter  their  nuclei. 

The  nucleus  of  the  third  nerve  receives  fibers  from 
the  anterior  corpus  quadrigeminum,  and  probably  simi- 
lar fibers  pass  to  the  nuclei  of  the  fourth  and  sixth 
nerves. 


AI^ATOMY. 


29 


Tlie  sixtli  and  seventh  nerves  are  closely  connected 
at  one  point  in  their  course.  The  sixth  enters  the  an- 
terior aspect  of  the  pons  just  at  its  junction  with  the 
medulla  oblongata  not  far  from  the  median  line.  It 
crosses  the  pons,  changing  its  direction  several  times  so 
that  no  one  section  can  follow  its  whole  course,  and 
enters  its  nucleus  just  external  to  the  eminentia  teres 
near  the  median  raphe  on  the  floor  of  the  fourth  ven- 


FiG,  11  represents  sections  through  the  pons,  so  as  to  show  on  the  left  the 
seventh  and  sixth  nerves,  with  their  nuclei ;  on  the  right,  the  sixth  and 
eighth  nerves,  half  schematic. 

VII,  seventh  nerve  ;  vn',  eminentia  teres,  where  the  seventh  nerve  tm'ns  down- 
ward ;  vii",  the  proper  nucleus  of  the  seventh  nerve ;  vi,  sixth  nerve ;  vi',  the 
common  nucleus  of  sixth  and  seventh ;  vin,  eighth  nerve ;  vm',  its  nucleus  ;  v, 
ascending  root  of  the  fifth  nerve ;  r,  restiform  body  ;  so,  the  superior  olive ;  ^,  the 
peduncular  fibers. 

tricle.  This  nucleus  is  also  the  origin  of  some  of  the 
fibers  going  to  the  seventh  nerve,  which  enters  the  pons 
just  anterior  (forward)  to  the  eighth,  crosses  diagonally 
in  a  gentle  curve  to  this  nucleus,  from  which  it  receives 
some  fibers ;  then  it  can  be  followed  to  the  eminentia 
teres,  where  it  turns  downward  ;  it  soon  turns  again  to 
pass  forward  and  outward,  slightly  downward,  to  its  in- 
ferior nucleus.  The  fibers,  in  passing  from  the  eminen- 
tia teres  to  this  nucleus,  divide  and  separate  more  or 


30 


DISEASES  OF  TEE  BRAIN. 


less  widely  from  each  other,  and  form  a  wide  network , 
rather  than  a  compact  bundle.  The  nucleus  Is  com- 
posed of  three  or  four  groups  of  cells,  in  each  section, 
which  are  each  surrounded  by  separate  bundles  of 
fibers.  Just  outside  the  facial  nerve,  and  anterior  to 
its  inferior  nucleus,  is  the  ascending  root  of  the  fifth 
nerve. 

From  the  nucleus  of  the  sixth  nerve  thin  bundles 
of  fibers  pass  forward  (upward)  in  the  posterior  longi- 
tudinal fasciculus  to  the  third  and  fourth  nerves.  These 
communicating  fibers  decussate  in  their  course  quite 
near  the  point  where  they  unite  with  the  other  fibers 
of  the  third  and  fourth  nerves. 

The  course  of  the  eighth  nerve  is  not  as  yet  of  so 


Fig.  12. — Transverse  section  of  the  medulla  on  the  right  at  a  higher  level  than 
on  the  left.    (After  Wernicke.) 

P,  the  anterior  pyramidal  fibers ;  6>,  the  inferior  olivary  body ;  Ic^  tlae  lateral 
column ;  cr,  the  restiform  body ;  pc^  the  posterior  columns  ;  /,  longitudinal  fibers ; 
c,  central  canal ;  Fa,  ascending  root  of  the  fifth ;  x,  xi,  xii,  the  corresponding 
nerves;  x',  xi',  xii',  their  nuclei;  x",  anterior  vagus  nucleus. 


A2rAT0Mr. 


31 


much  practical  interest.  It  enters  tlie  pons  just  behind 
(below)  the  seventh,  and  divides  into  three  bundles, 
which  are  distributed  to  separate  nuclei.  It  is  scarcely- 
necessary  to  give  the  particulars  of  its  deep  origin. 


Fig.  13. — Schematic  view  of  the  relative  situations  of  the  nuclei  in  the  medulla. 

(After  Erb.) 

v-xn,  the  nerves  or  their  nuclei ;  1,  middle,  2,  superior,  3,  inferior  cerehellar 
peduncle;  4, restiform hody ;  5,  eminentia teres  ;  6, acoustic  fibers ;  7,alacinerea. 

The  relations  and  origins  of  the  nerves  of  the  me- 
duUa  oblongata  can  be  easily  learned  by  a  study  of  the 
accompanying  figures  (12  and  13),  and  it  is  scarcely 
necessary  to  give  more  detailed  descriptions. 

The  distribution  of  the  blood-vessels  in  the  brain 
has  been  studied  especially  by  Duret.  The  results  ob- 
tained are  of  much  practical  value.     The  circle  of  WH- 


S2  DISEASES  OF  TEE  BRAIN. 

lis  at  the  base  of  tlie  brain  f urnislies  rather  free  com- 
nnmication  between  the  carotids  and  the  vertebrals  of 
the  same  side,  and  between  the  arteries  at  the  posterior 
part  of  the  brain  on  opposite  sides,  unless  there  are 
anomalies  in  the  size  of  the  arteries.  Anteriorly,  the 
only  communication  between  the  two  carotids  is  the 
anterior  communicating  artery. 

The  nutrient  arteries  for  the  corpus  striatum  and 
optic  thalamus  arise  from  the  first  few  centimetres  of 
the  anterior,  middle,  and  posterior  cerebral  arteries  ; 
those  from  the  posterior  cerebral  are  distributed  to  the 
optic  thalamus,  the  others  to  the  caudate  and  lenticular 
nuclei.  These  nutrient  arteries  arise,  then,  from  a  posi- 
tion where  they  are  the  more  likely  to  feel  any  increase 
of  blood-pressure  ;  anastomoses  between  the  secondary 
arteries  supplying  these  regions  are  very  unusual. 

The  convolutions  are  supplied  with  blood-vessels 
from  the  pia  mater  covering  them.  The  anastomoses 
between  the  different  arterial  systems  in  the  pia  mater 
are  very  few  and  unimportant.  The  arterioles,  after 
entering  the  gray  substance,  quickly  subdivide  into  the 
minutest  branches  ;  these  anastomose  freely  with  each 
other.  The  vessels  for  the  subjacent  white  substance 
pass  through  the  cortical  layers,  giving  off  only  a  few 
branches,  and  finally  subdivide  in  the  medullary  sub- 
stance into  elongated  meshes.  There  are  no  important 
anastomoses  between  the  arteries  of  the  convolutions 
and  those  of  the  large  ganglia  at  the  base,  even  where 
the  two  come  very  near  together,  as  in  the  corpus  stri- 
atum opposite  the  insula. 

The  veins  anastomose  more  freely,  and  are  so  dis- 
posed with  reference  to  the  arteries  of  the  convolutions 
that  the  blood  is  delayed,  especially  in  the  arterioles  in 
the  gray  substance,  and  the  nerve-cells  are  continuous- 
ly bathed  in  arterial  blood. 

As  the  arteries  branch  at  nearly  right  angles,  and 
subdivide  rapidly  into  very  small  vessels,  the  blood- 
pressure  is  diminished ;  but  the  absence  of  communi- 


'  PHYSIOLOGY.  33 

cations  between  the  larger  branches  does  not  allow  of 
the  removal  of  pressure  from  weakened  arteries. 

Most  of  the  first  and  second  frontal  convolutions, 
and  the  convolutions  in  the  median  fissure  as  far  back 
as  the  termination  of  the  sulcus  calloso-marginalis,  are 
supplied  by  the  anterior  cerebral  arteries.  The  third 
frontal  convolution,  the  anterior  central  and  posterior 
central,  and  very  nearly  all  the  parietal  and  the  upper 
part  of  the  temporal  lobes  and  the  insula,  are  supplied 
by  the  middle  cerebral.  The  lower  portion  of  the  tem- 
poral and  the  occipital  lobes  are  supplied  by  the  pos- 
terior cerebral  artery. 

One  of  these  arteries,  or  any  of  their  branches,  may 
be  obstructed  mechanically,  or  may  be  subject  to  tem- 
porary reflex  spasms,  so  as  to  interfere  with  the  proper 
flow  of  blood.  Hypersemia  may  also  affect  any  one  dis- 
trict, leaving  the  others  nearly  unaffected. 

PHYSIOLOGY. 

Fritsch  and  Hitzig  (1870)  first  called  attention  to  the 
irritability  of  certain  districts  of  the  cerebral  cortex  as 
suggesting  the  localization  of  motor  functions  in  sepa- 
rate and  distinct  regions  of  the  brain.  Ferrier  soon 
after  (1873)  published  observations  made  in  the  same 
direction,  and  has  since  greatly  extended  our  knowl- 
edge. During  the  last  ten  years  the  literature  of  the 
subject  has  increased  wonderfully. 

The  region  of  the  cortex  immediately  anterior  and 
posterior  to  the  fissure  of  Rolando  has  been  found  to 
be  excitable ;  an  irritation  applied  to  this  region  causes 
motion  in  the  voluntary  muscles,  according  to  the  lo- 
cality of  the  irritation.  Other  regions  may  be  excitable, 
and  probably  are,  but  the  above  central  region  is  the 
one  which  seems  to  act  most  directly  upon  the  limbs. 
When  motion  is  produced  by  irritation  of  other  regions, 
it  is  probably  indirect.  Other  regions  than  these  may, 
when  irritated,  cause  various  sensations  or  give  rise  to 
mental  actions ;  but  these  are  not  revealed  to  us  by 


34 


DISEASES  OF  THE  BRAIK 


motor  phenomena.  A  careful  study  of  Ferrier's  plate, 
with  the  motor  centers  marked  on  Ecker's  diagram  of 
the  convolutions,  will  be  all  that  is  needed  to  fix  these 
centers  in  the  mind. 


Pig.  14. — Location  of  motor  and  other  centers  in  the  cerebral  cortex.  (Terrier.) 

1,  on  the  upper  or  superior  parietal  lohule  center  for  the  opposite  leg ;  2,  3,  4, 
around  the  upper  end  of  central  fissure,  centers  for  opposite  leg,  arm,  and 
trunk ;  5,  centers  for  motion  of  opposite  arm  and  hand  forward ;  a,  h,  c,  d,  on  the 
posterior  central  convolution,  centers  for  motions  of  fingers  and  wrist  of  opposite 
hand ;  6,  supination  and  flexion  of  the  opposite  forearm ;  7,  8,  9, 10,  11,  on  the 
anterior  central  convolution  and  around  the  base  of  central  fissure,  motions  of 
mouth,  lips,  and  tongue  (9, 10  are  called  oro-lingual  centers  by  Fender) ;  12,  eleva- 
tion of  eyelids,  dilatation  of  pupils,  conjugate  deviation  of  eyes,  and  turning  of 
head  to  opposite  side  ;  13, 13',  centers  which  seem  to  have  relation  to  vision  and 
cause  motions  of  the  eyes ;  14,  centers  which  seem  to  be  concerned  with  hearing, 
and  give  rise  to  motions  expressive  of  attention. 

The  views  as  to  the  sensory  centers  are  still  unset- 
tled. It  is  much  more  difficult  to  locate  these ;  and, 
indeed,  the  facts  as  yet  known  rather  tend  to  show  that 


PHTSIOLOGT. 


35 


the  centers  for  different  sensations  are  mucli  less  clearly 
defined  than  those  for  motion. 

Ferrier  locates  the  centers  for  sensation  in  the  pari- 
eto-temporal  region ;  sight  in  the  supra-marginal  and 
angular  convolutions  (13,  13') ;  hearing  in  the  superior 


Fig.  15. — Location  of  motor  and  other  centers  in  the  cerebral  cortex.   (Ferrier.) 
Lettering  same  as  Fig.  14. 

or  first  temporal  convolution  (14) ;  taste  and  smell  in 
the  lower  extremity  of  the  temporo-sphenoidal  lobe — 
region  of  the  subiculum  cornu  Ammonis ;  tactile  sensa- 
tion in  the  region  of  the  hippocampus.  The  centers  for 
sight  and  hearing  are  probably  correctly  located,  but 
there  are  also  centers  for  sight  in  the  occipital  lobe 


36  DISEASES  OF  TEE  BRAIN. 

quite  as  important  as  those  in  the  angular  and  sui^ra- 
marginal  convolutions.  There  is  some  uncertainty  as 
to  the  other  sensory  centers. 

Petrina  is  of  opinion  that  the  faculty  of  sensation  is 
more  generally  diffused,  and  that  at  least  the  fibers  for 
tactile  sensation  follow  the  motor  fibers  to  the  motor 
centers,  and  terminate  there  in  sensory  cells.  Thus  he 
regards  each  motor  center  as  also  in  some  degree  sen- 
sory. 

The  location  of  the  centers  for  tactile  sensation  must 
be  considered  as  undetermined.  It  is,  however,  settled 
that  the  sensory  fibers  pass  through  the  posterior  thu-d 
of  the  posterior  limb  of  the  internal  capsule,  through 
the  outer  part  of  the  cerebral  peduncle,  the  lateral  part 
of  the  pons  Varolii  near  the  floor  of  the  fourth  ventricle, 
to  the  sensory  region  of  the  cord. 

The  fibers  of  the  corona  radiata  may  be  classed  as 
motor  or  sensory,  according  to  the  portion  of  the  cortex 
with  which  they  are  connected.  Lesion  of  the  white 
fibers  passing  from  the  motor  centers  of  the  cortex  to 
the  internal  capsule  causes  serious  disturbance  of  mo- 
tion ;  if  extensive,  a  permanent  hemiplegia  of  the  oppo- 
site side  will  be  produced ;  if  limited,  they  may  give 
rise  to  monoplegias,  just  as  limited  lesions  of  the  cortical 
motor  zone. 

Following  these  fibers  into  the  internal  capsule, 
Franck  and  Pitres  found :  1.  Quite  in  front  the  fibers 
which,  on  irritation,  cause  motion  in  the  face  and  eye- 
lids on  the  opposite  side.  2.  N'ext  behind,  the  fibers  for 
the  anterior  limbs  on  the  opposite  side.  3.  A  bundle 
of  fibers  which  move  both  limbs  on  the  opposite  side. 
4.  A  very  small  bundle  for  the  opposite  hind  limb.  5. 
In  the  posterior  part  of  the  caudate  nucleus  those  which 
cause  elevation  of  the  opposite  ear. 

These  experiments  were  made  upon  animals  ;  clini- 
cal observations  and  post-mortem  examinations  must 
finally  show  how  nearly  the  same  order  is  followed  in 
man. 


GENERAL  SYMPTOMATOLOGY.  37 

The  functions  of  the  ganglia  at  the  base  are  not  yet 
well  determined.  We  know  nothing  in  regard  to  the 
functions  of  the  caudate  and  lenticular  nucleus ;  they 
do  not  seem  to  have  any  direct  control  over  either  mo- 
tion or  sensation,  which  has  as  yet  been  discovered. 

The  functions  of  the  optic  thalamus  are  still  a  subject 
for  investigation  and  discussion.  Nothnagel,  from  ex- 
periments on  animals,  concludes  that  motor  impulses, 
which  are  excited,  or  depend  upon  peripheral  sensory 
impressions,  take  their  origin  in  the  optic  thalami. 

Wernicke's  conclusions  agree  very  nearly  with  this 
view.  "  They  serve,  1,  for  acquiring  consciousness  of 
motions  through  'muscular  sense'  or  innervation's 
sense ;  2,  for  the  involuntary  adaptation  of  our  motions 
to  external  relations  by  means  of  the  reflex  mechan- 
ism which  they  contain  ;  3,  as  a  way  for  certain  sensory 
tracts,  which,  according  to  Meynert,  serve  for  trans- 
mission of  muscular  or  innervation's  sense." 

The  posterior  portion  of  the  optic  thalamus,  the 
pulvinar,  forms  a  part  of  the  visual  centers  ;  it  stands 
in  intimate  relations  with  the  corresponding  halves  of 
both  retinas,  as  is  shown  by  the  symptoms  in  cases 
where  it  is  destroyed.  Exactly  how  these  relations 
are  maintained  is  not  yet  definitely  known. 

The  physiology  of  the  pons,  medulla,  and  neighbor- 
ing parts  can  be  inferred  from  the  anatomical  descrip- 
tions given  above,  or  will  be  mentioned  more  conven- 
iently in  connection  with  the  symptoms  due  to  their 
lesion  in  the  following  sections. 

GENERAL  SYMPTOMATOLOGY. 

Lesions  affecting  the  brain  may  be  divided  into  two 
classes,  destructive  and  irritative.  These  may  act  only 
upon  the  nerve-fibers  which  they  immediately  affect ; 
or  they  may  exert  an  influence  at  a  distance,  which 
may  be  different  in  its  nature  from  their  immediate  in- 
fluence.   A  haemorrhage  ^vill  destroy  nerve-fibers,  which 


38  DISEASES  OP  THE  BRAIN. 

are  torn  across ;  it  will  also,  if  of  sufficient  size,  inter- 
fere with  the  function  of  others  by  compressing  them, 
and  it  may  give  rise  to  symptoms  of  irritation.  A 
tumor  may  irritate  certain  fibers,  and,  by  compression, 
prevent  the  action  of  others,  or  it  may  destroy  those 
among  which  it  grows,  and  irritate  others  at  a  dis- 
tance. As  a  rule,  a  lesion  which  occurs  suddenly,  as  a 
haemorrhage,  will  give  rise  to  more  symptoms  depend- 
ing upon  interference  with  distant  regions  than  those 
lesions  which  slowly  increase  in  size.  It  may  be  neces- 
sary, then,  in  forming  an  opinion  as  to  the  seat  of  a 
lesion,  to  wait  until  the  commotion  produced  by  the 
first  shock  of  the  disturbance  has  subsided  and  the 
remote  symptoms  have  disappeared. 

Destruction  of  the  motor  centers,  or  of  the  white 
fibers  of  the  corona  radiata  underlying  these  centers, 
is  revealed  by  paralysis  of  the  limbs  or  muscles  over 
which  they  preside.  Irritation  of  these  parts  gives  rise 
to  spasm  of  those  muscles.  It  may  happen  that  there 
is  first  an  irritation  due  to  the  destruction  of  fibers, 
shown  by  a  spasm  ;  then  follows  the  paralysis  depend- 
ent upon  the  permanent  lesion.  If  the  irritation  is 
very  strong,  it  not  only  excites  to  activity  the  center 
on  which  it  first  acts,  but  neighboring  centers,  and  per- 
haps the  whole  motor  area  of  both  hemispheres,  may  be 
thrown  into  commotion  ;  then  general  convulsions  will 
result. 

By  a  careful  study  of  the  seat  of  the  paralysis  or 
convulsion,  and  a  comparison  of  these  with  the  motor 
centers,  a  reasonably  accurate  conclusion  as  to  the  seat 
of  a  cortical  lesion  may  be  formed.  Spasms  confined 
to  one  limb  are  much  more  clearly  diagnostic  of  corti- 
cal lesion  than  paralysis.  When  convulsions  are  gen- 
eral, the  diagnosis  is  less  certain ;  but,  by  watching  the 
commencement  of  the  attack,  noting  that  invariably 
the  same  limb  is  first  affected  each  time,  and  that  the 
convulsions  follow  the  same  course,  a  correct  diagnosis 
may  often  be  made. 


GENERAL  SYMPTOMATOLOGY.  39 

The  caudate  nucleus  and  the  lenticular  ganglion 
may  be  nearly  or  quite  destroyed  without  any  disturb- 
ance of  motion  or  sensation.  Grenerally,  however,  es- 
pecially if  the  destruction  is  produced  by  a  haemor- 
rhage, there  is  more  or  less  compression  of  neighboring 
parts,  the  internal  capsule  is  thereby  disturbed,  and 
symptoms  result  therefrom.  Often,  also,  a  portion  of 
the  capsule  is  destroyed,  and  then  the  symptoms  are 
permanent.  If  the  destruction  is  limited  to  the  gray 
ganglia,  as  the  clot  is  absorbed  the  pressure  upon  the 
capsule  is  removed,  and  the  symptoms  may  entirely 
disappear. 

The  optic  tJialamus  may  be  partially  destroyed  with- 
out special  symptoms ;  those  which  occur  seemingly 
depend  upon  pressure  or  implication  of  neighboring 
parts.  At  other  times  there  are  disturbances  of  sensa- 
tion which  seem  to  arise  directly  from  the  lesion  of  the 
thalamus.  Injuries  to  the  optic  thalamus  may  cause 
more  or  less  disturbance  of  vision.  When  the  anterior 
or  middle  portions  are  injured,  this  disturbance,  if 
present,  is  temporary ;  if  the  posterior  part,  the  pul- 
vinar,  is  injured,  the  loss  of  vision  is  permanent,  and 
generally  affects  only  one  half  the  visual  field — hemi- 
anopsia. 

There  is  a  small  region,  carrefour  sensitif^  lying 
external  to  the  pulvinar,  which  serves  as  the  course  for 
sensory  fibers.  Lesion  of  this  region  will  give  rise  to 
hemiansesthesia  ;  and  when  there  is  disease  of  the  optic 
thalamus  or  pulvinar,  this  region  would  very  likely  be 
disturbed. 

A  peculiar  motor  disturbance  is  associated  with 
injury  of  the  posterior  and  outer  part  of  the  optic 
thalamus,  and  perhaps  adjacent  parts,  though  some 
observations  seem  to  show  that  lesion  of  the  thalamus 
alone  is  sufficient  to  produce  the  phenomena.  The  par- 
tially or  entirely  paralyzed  limbs  are  in  a  state  of  un- 
rest ;  they  keep  up  a  constant  motion,  which  may  be  sim- 
ply a  tremor,  or  a  slow,  irregular  motion  in  all  directions 


40  DISEASES  OF  THE  BRAIK 

withont  co-ordination  or  rhythm,  sometimes  resembling 
chorea,  sometimes  peculiar  and  unlike  any  other  motor 
phenomena.  This  has  been  called  athetosis,  or  post- 
Jiemiplegic  chorea. 

The  internal  capsule  is  the  most  important  part  of 
the  base  of  the  brain,  so  far  as  relates  to  the  symptoms 
arising  from  its  destruction. 

When  the  anterior  limb  of  the  internal  capsule  is 
destroyed,  secondary  degeneration  affects  only  the  in- 
ternal segment  of  the  base  of  the  crus,  and  this  degen- 
eration can  not  be  followed  beyond  the  pons.  When 
the  anterior  two  thirds  of  the  posterior  limb  are  de- 
stroyed, there  is  descending  degeneration,  which  can  be 
followed  through  the  middle  segment  of  the  crus,  the 
pons,  medulla,  and  anterior  pyramids,  where  it  crosses 
to  the  opposite  side  of  the  cord,  excepting  a  small  por- 
tion, the  anterior  pyramidal  fibers,  which  pass  down- 
ward on  the  same  side.  When  the  outer  third  of  the 
posterior  limb  is  destroyed,  there  is  no  descending  de- 
generation. Hence  we  conclude  that  the  most,  if  not 
all,  of  the  motor  fibers  for  the  trunk  and  limbs  from  the 
motor  area  of  the  brain  pass  through  the  anterior  two 
thirds  of  the  posterior  limb  of  the  internal  capsule,  and 
follow  the  course  taken  by  the  descending  degeneration. 

When  the  anterior  limb  of  the  internal  capsule  is 
destroyed,  there  is  no  paralysis  of  the  limbs  ;  the  facial 
nerve  may  be  paralyzed. 

When  the  anterior  two  thirds  of  the  posterior  limb 
are  destroyed  (or  pressed  upon  so  as  to  interfere  with 
function),  there  is  always  paralysis  of  motion  in  the  op- 
posite side'  of  the  body.  This  paralysis  is  permanent, 
and  is  followed  by  late  contraction,  due  to  secondary 
degeneration  of  the  pyramidal  tract. 

When  the  posterior  third  of  the  posterior  limb  is 
destroyed,  there  is  anaesthesia  of  the  opposite  side ; 
Charcot  calls  this  cerebral  hemiansesthesia,  and  says  it 
is  a  faithful  reproduction  of  the  characteristics  of  hys- 
terical hemiansesthesia ;  the  insensibility  extends  to  the 


GENERAL  SYMPTOMATOLOGY.  41 

profound  parts,  muscles,  mucous  membranes  ;  it  in- 
volves also  the  sensory  ai^paratus,  the  senses  of  taste 
and  hearing,  of  smell  and  sight.  The  sight  is  lost  by  a 
concentric  narrowing  of  the  field  of  vision  ;  the  percep- 
tion of  colors  is  lost — first  green,  then  red,  orange,  yel- 
low, and  blue,  until  everything  has  a  grayish  hue. 

When  disease  of  one  hemisphere  causes  amblyopia 
or  amaurosis,  the  disturbance  of  vision  is  observed  in 
the  opposite  eye ;  a  slight  defect  may  also  be  discov- 
ered in  the  corresponding  eye  if  carefully  sought,  pro- 
vided the  intelligence  of  the  patient  is  not  too  much 
disturbed.  The  lesion  is  then  situated  in  the  posterior 
third  of  the  posterior  limb  of  the  inner  capsule,  or  in 
some  portion  of  the  cortex  which  is  not  yet  exactly 
located,  but  which  probably  corresponds  to  Ferrier's 
centers  (13,  13')  in  the  angular  gyrus,  or  it  may  be  in 
some  portion  of  the  occipital  lobe. 

Many  times  the  loss  of  vision  affects  only  one  lateral 
half  of  the  visual  field.  This  is  called  hemiopia,  in 
speaking  of  the  loss  of  power  in  the  retina,  or  more 
usually  hemianopsia,  as  referring  to  the  visual  field. 

When  there  is  double  temporal  hemianopsia — the 
loss  of  sight  affecting  the  temporal  half  of  both  visual 
fields — the  lesion  must  be  in  the  chiasma,  probably  near 
its  anterior  border,  at  a.  Fig.  8. 

When  the  nasal  half  of  the  visual  field  is  lost — nasal 
hemianopsia — the  lesion  must  be  on  the  corresponding 
side  of  the  chiasma,  5,  Fig.  8 ;  both  sides  are  rarely 
thus  affected.  If  there  is  amblyopia  or  amaurosis  of 
one  eye  and  nasal  hemianopsia  of  the  other  eye,  the 
lesion  must  be  on  the  side  of  the  chiasma  correspond- 
ing with  the  amblyopic  eye,  and  penetrate  deep  enough 
to  affect  the  decussating  fibers. 

When  there  is  loss  of  vision  for  corresponding  lat- 
eral halves  of  both  visual  fields,  the  defect  is  called  lat- 
eral homonymous  hemianopsia.  This  may  be  caused 
by  lesion  of  the  opposite  optic  tract  (c,  Fig.  8),  of 
the  pulvmar,  of  the  occipital  lobe,  or  possibly  of  the 


42  DISEASES  OF  TEE  BBAIN. 

angular  gyrus,  or  of  the  fibers  passing  from  the  pulvi- 
nar  to  the  centers  of  vision.  If  there  is  no  reaction  of 
the  pupil  when  light  falls  upon  the  affected  half  of  the 
retina,  the  lesion  must  be  in  the  optic  tract  or  the  ante- 
rior corpus  quadrigeminum — i.  e.,  in  right  lateral  he- 
mianopsia the  left  optic  tract  would  be  affected. 

If  the  pupil  reacts  when  light  falls  upon  the  affected 
half  of  the  retina,  the  lesion  is  either  in  the  pulvinar, 
in  the  corona  radiata,  or  the  cortex.  When  the  pul- 
vinar is  the  seat  of  a  haemorrhage,  there  may  be  other 
symptoms  of  apoplexy,  motor  or  sensory;  these  will 
disappear  in  a  short  time,  but  the  hemianopsia  will  be 
permanent.     There  may  be  photopsia. 

When  the  corona  radiata  leading  to  the  centers  of 
vision  is  the  seat  of  haemorrhage,  the  hemianopsia  will 
at  first  be  complete,  but  soon  the  vision  will  be  partially 
restored  ;  there  wiU  be  other  apoplectic  symptoms.  If 
the  loss  of  sight  is  caused  by  tumor,  it  will  come  on 
gradually,  and  will  be  accompanied  by  other  symptoms 
— paralysis  of  cranial  nerves,  etc. — showing  the  nature 
and  seat  of  the  lesion.     Photopsia  may  be  present. 

When  the  cortical  centers  of  vision  are  affected,  there 
will  be  no  photopsia  ;  the  hemianopsia  may  be  complete 
or  only  partial ;  there  may  be  loss  of  perception  of  color 
in  one  half  of  the  visual  field,  with  power  to  perceive 
white.     There  will  be  no  other  paralysis  except  vision. 

Charcot  and  his  followers  claim  that  lesion  of  the 
hemispheres  is  more  frequently  followed  by  amblyopia, 
contraction  of  the  field  of  vision,  and  that  hemianopsia 
is  rare.  Fere  thinks  the  lesion  causing  hemianopsia 
must  be  situated  between  the  angular  gyrus  and  the 
fissure  of  Rolando,  or  in  the  medullary  fibers  leading 
from  that  region.  We  do  not  yet  know  why  in  one 
case  there  is  hemianopsia  and  in  another  amblyopia. 

When  the  lesion  is  situated  below  the  internal  cap- 
sule, so  that  the  cms  cerebri,  or  parts  below,  are  impli- 
cated, the  cranial  nerves  may  be  affected  on  the  same 
side  with  the  lesion.     The  symptoms  may  then  be  in 


GENERAL  SYMPTOMATOLOGY.  43 

part  on  the  same  side,  in  those  nerves  directly  affected ; 
in  part  on  the  opposite  side,  for  the  nerves  arising  below 
the  seat  of  the  disease.  This  gives  a  crossed  or  alter- 
nate paralysis.  A  comparison  of  the  symptoms  with 
the  physiology  and  anatomy  of  this  part  of  the  mesen- 
cephalon will  lead  to  as  correct  a  diagnosis  of  the  loca- 
tion of  the  lesion  as  can  be  made. 

Lesions  of  the  anterior  corpora  quadrigemina  are 
attended  with  partial  or  total  loss  of  vision.  If  the 
lesion  is  unilateral,  the  loss  of  vision  is  also  unilateral. 
Opinions  differ  as  to  whether  there  is  simple  unilateral 
amaurosis  or  lateral  hemianopsia. 

Lesions  of  the  posterior  corpora  quadrigemina  are 
associated  with  inco-ordination,  which  Nothnagel  says 
is  like  that  found  in  lesion  of  the  cerebellum,  and  which 
is  possibly  dependent  upon  a  coincident  lesion  of  the 
superior  cerebellar  peduncle. 

These  symptoms  alone  would  not  be  suflBLcient  to 
locate  the  lesion  in  the  corpora  quadrigemina.  There 
will  often  be  found  other  symptoms  due  to  extension 
of  the  lesion  to  neighboring  parts. 

The  third  and  fourth  nerves,  with  their  nuclei,  lie 
just  below  the  corpora  quadrigemina,  and  may  be  im- 
plicated ;  then  there  would  be  partial  or  entire  paraly- 
sis of  these  nerves.  The  motor  and  sensory  tracts  pass 
through  the  crura  cerebri,  and  may  be  implicated,  giv- 
ing rise  to  corresponding  symptoms. 

The  third  nerve  supplies  many  different  muscles.  Its 
most  anterior  fibers  are  for  accommodation  ;  just  behind 
these  are  the  fibers  which  innervate  the  sphincter  of  the 
iris ;  then  are  arranged  the  fibers  for  the  internal  rectus, 
the  superior  rectus,  the  levator  palpebrse  superioris,  the 
inferior  rectus,  and  the  inferior  oblique.  *    When  the 

*  Kahler  and  Pick  suggest  that  the  posterior  bundles  supply  the  le- 
vator palpebrse,  rectus  superior,  and  obliquus  inferior — muscles  which 
are  employed  together  in  looking  upward;  that  the  posterior  median 
bundles  innervate  the  internal  rectus  and  the  inferior  rectus ;  the  an- 
terior, the  pupillary,  and  accommodation  muscles. 


44  DISEASES  OF  TEE  BRAIN. 

nucleus  or  the  nerve  in  its  course  througli  tlie  peduncle 
is  affected,  the  symptoms  will  guide  to  a  diagnosis  of 
the  seat  of  the  disease.  Kahler  and  Pick  say  a  disas- 
sociated, partial  paralysis  of  the  oculo-motor  nerve 
points  primarily  to  a  lesion  of  the  territory  through 
which  the  roots  of  this  nerve  run. 

Most  significant  for  lesion  of  the  cerebral  pedun- 
cles is  the  alternate  paralysis  of  the  motor-oculi  nerve. 
The  limbs  and  face,  perhaps  also  the  tongue,  are  para- 
lyzed on  one  side,  opposite  to  the  lesion ;  the  ocular 
muscles  are  paralyzed  on  the  other  side,  the  same  side 
with  the  lesion.  Great  disturbance  of  sensation  would 
indicate  that  the  outer  portion  of  the  cms  was  affected. 

In  case  of  disease  of  the  pons  Varolii  a  few  symp- 
toms are  important ;  among  these,  alternate  paralysis, 
the  limbs  affected,  as  to  motion  and  sensation,  on  the 
side  opposite  the  lesion,  the  cranial  nerves  on  the  same 
side  with  the  lesion ;  whether  the  facial,  the  fifth,  the 
sixth,  are  all  or  only  in  part  paralyzed  on  the  side  op- 
posite the  limbs,  depends  upon  the  height  at  which  the 
disease  is  situated.  If  there  is  thus  alternate  paralysis, 
the  disease  is  almost  sure  to  be  in  the  pons,  sometimes 
it  may  be  in  the  medulla  oblongata. 

A  conjugate  deviation  of  the  eyes  to  one  side  is  diag- 
nostic of  lesion  of  the  pons,  when,  in  case  of  paralysis, 
the  eyes  are  turned  toward  the  hemiplegic  side ;  in  case 
of  spasm,  away  from  that  side.  This  symptom  points 
to  the  vicinity  of  the  nucleus  of  the  sixth  nerve  as  the 
locality  of  the  lesion. 

Conjugate  deviation  of  the  eyes  is  found,  associated 
with  deviation  of  the  head  to  the  same  side  as  the  eyes, 
in  cases  of  haemorrhage  into  the  hemispheres.  Then 
the  symptom  is  of  only  short  duration  ;  in  a  few  hours 
or  a  few  days  the  motions  of  the  eyes  and  head  become 
free.  Under  these  circumstances  it  is  of  little  value  in 
locating  the  lesion ;  it  may  accompany  superficial  le- 
sions, or  those  which  involve  the  cerebral  substance, 
becoming  more  frequent  as  the  lesion  is  situated  nearer 


GENERAL  SYMPTOMATOLOGY.  45 

the  corpus  striatum  and  the  fibers  radiating  from  the 
cerebral  peduncle.  The  deviation  is  away  from  the 
paralyzed  side,  toward  the  affected  hemisphere  ;  when 
there  are  convulsions,  the  deviation  is  toward  the  side 
convulsed. 

When  conjugate  deviation  of  the  eyes  occurs  in  dis- 
ease of  the  pons,  it  is  usually  independent  of  any  de- 
viation of  the  head,  and  is  persistent. 

In  examining  the  eyes,  it  is  necessary  to  examine 
them  together,  and  each  one  separately.  In  paralysis 
due  to  disease  of  the  pons,  the  abducens  on  the  same 
side  with  tlie  lesion  is  paralyzed  alternately  with  the 
limbs.  The  internal  rectus  then  draws  the  affected  eye 
toward  the  opposite  side.  The  internal  rectus  of  the 
other  eye,  on  account  of  the  union  of  the  sixth  nucleus 
vdth  the  third  nerve,  being  paralyzed,  so  far  as  acting 
in  harmony  witli  the  opposite  abducens,  allows  that 
eye  to  be  drawn  outward  by  its  external  rectus.  As 
the  fibers  of  the  third  nerve,  which  control  the  direc- 
tion of  the  eyes  for  near  vision,  are  not  paralyzed, 
being  independent  of  the  sixth  nerve,  both  eyes  vsdll 
turn  inward  naturally  when  an  object  is  slowly  ap- 
proached to  the  eyes.  When  examined  separately,  the 
eye  whose  abducens  is  paralyzed  can  not  be  turned 
outward  beyond  the  median  line ;  the  other  eye  can  be 
turned  inward,  though,  it  may  be,  only  with  consid- 
erable effort.  In  this  separate  examination  of  each  eye 
some  nystagmus  may  be  noticed. 

"When  the  abducens  alone  of  the  ocular  nerves  is 
paralyzed,  the  pons  must  be  the  seat  of  the  disease, 
unless  other  symptoms  show  that  the  lesion  is  pe- 
ripheral. 

When  only  one  pupil  is  persistently  contracted, 
lesion  of  the  pons  on  the  same  side  is  indicated. 

When  speech  is  affected,  it  is  in  the  form  of  anar- 
thria. 

The  sensory  fibers  are  said  to  pass  through  the  lat- 
eral portions  of  the  pons,  and  great  or  total  loss  of  sen- 


46  DISEASES  OF  THE  BRAIK 

sation  in  disease  of  the  pons  would  point  to  tliat  por- 
tion as  its  seat. 

Compulsory  motions  and  ataxia  would  be  rather 
indicative  of  lesion  of  the  cerebellar  peduncle  than  of 
the  pons,  though  Penzoldt  noticed  compulsory  motion 
backward  when  the  middle  portion  of  the  pons  was 
affected. 

When  the  cerebellum  is  the  seat  of  a  tumor,  many 
symptoms  will  be  caused  by  pressure  upon  neighboring 
parts ;  also  in  case  of  haemorrhage  the  earlier  symptoms 
may  be  in  part  due  to  the  effects  of  influences  acting 
upon  other  regions.  In  disease  of  the  cerebellum,  vom- 
iting is  a  very  common  symptom  ;  optic  neuritis  is  fre- 
quent ;  the  ventricles  may  be  distended  with  serum. 
The  most  characteristic  symptom  is  motor  disturbance, 
a  general  weakness  and  a  disturbance  of  co-ordination, 
with  vertigo  and  uncertainty  of  gait.  This  disturbance 
of  gait  is  found  only  when  the  vermiform  process  or 
the  middle  lobe  of  the  cerebellum  is  affected.  When 
the  middle  lobe  is  diseased,  there  is  likely  to  be  pria- 
pism. The  cerebellar  hemispheres  may  be  extensively 
diseased  without  causing  characteristic  symptoms. 

The  symptoms  at  a  distance  due  to  pressure,  etc., 
will  generally  be  a  great  aid  to  diagnosis,  and  without 
these  it  may  be  impossible  to  locate  the  disease. 

The  symptoms  caused  by  lesion  of  the  nuclei  in  the 
medulla  oblongata  will  be  described  under  Bulbar  Pa- 
ralysis. 

DISTURBANCES  OF  SPEECH. 

Speech  may  be  interfered  with  in  several  ways  :  1. 
The  power  of  transforming  thought  into  words  may  be 
lost  {amnesic  aphasia) ;  the  patient  may  yet  under- 
stand what  is  said  and  be  able  to  read.  The  loss  of 
speech  may  be  absolute,  or,  as  is  more  common,  the 
patient  may  retain  the  power  of  speaking  certain  words 
or  phrases  ;  these  expressions  are  usually  "yes"  and 
"no,"  which  may  be  used  correctly,  but  quite  as  often 


DISTURBANCES  OF  SPEECH.  47 

incorrectly  ;  certain  expressions  whicli  are  of  the  nature 
of  exclamations  and  oaths  may  be  retained.  The  ex- 
tent to  which  speech  is  affected  varies  greatly  ;  some- 
times patients  can  repeat  a  sentence  spoken  in  their 
hearing,  sometimes  can  read  aloud,  yet  immediately 
after  are  unable  to  say  the  same  words ;  sometimes 
they  can  spontaneously  speak  a  part  of  a  sentence,  or 
they  may  occasionally  be  at  a  loss  for  a  word,  and  rec- 
ognize it  when  suggested.  Sometimes  only  one  class 
of  words  is  lost,  as  nouns,  or  words  expressing  relations 
or  adjectives. 

When  the  loss  of  the  faculty  of  recollecting  words 
is  marked,  there  is  also  a  loss  in  the  power  of  express- 
ing thought  by  gestures  {amimia\  and  the  patient  can 
not  write,  even  if  the  motions  of  the  hand  would  permit 
writing  {agraphia).  They  are  unable  to  write  with  the 
left  hand.  In  attempting  to  write,  sometimes  only  lines 
are  made,  sometimes  separate  letters,  but  not  words ; 
or  words  may  be  written,  but  not  to  form  sentences. 

2.  The  patient  may  have  the  power  to  change 
thought  into  words,  but  the  connection  between  the 
center  where  this  is  done  and  the  vocal  organs  is  inter- 
rupted, and  the  patient  can  not  express  himself.  This 
is  called  ataxic  aphasia,  or  anarthria  ;  the  lesion  may 
be  at  any  point  between  the  speech-centers  and  the 
vocal  organs.  When,  however,  the  nuclei  of  the  nerves 
in  the  medulla  are  diseased,  peculiar  difficulties  of  ut- 
terance are  produced  which  are  not  properly  included 
under  this  title,  and  which  will  be  considered  in  con- 
nection with  bulbar  paralysis. 

Under  the  name  dysarthria  may  be  included  cer- 
tain disturbances  of  speech,  as  stuttering,  explosive 
speech,  scanning  speech,  trembling  speech,  etc. 

When  there  is  anarthria,  ataxic  aphasia,  the  patient 
is  unable  (according  to  the  degree  of  loss  of  power)  not 
only  to  speak,  but  he  is  also  unable  to  read ;  he  may, 
however,  be  able  to  express  himself  by  gestures  and  by 
writing. 


4:8  DISEASES  OF  THE  BRAm. 

3.  A  peculiar  disturbance  of  the  faculty  of  speech 
has  been  attracting  attention  lately.  The  patient  is 
able  to  hear  sounds  or  -see  objects ;  he  is  able  to  origi- 
nate thought  and  give  expression  to  his  thought  in 
words  more  or  less  appropriate  ;  but  words  spoken  con- 
vey to  him  no  ideas,  or  words  written  are  not  recog- 
nized as  words.  There  is,  as  named  by  Kussmaul, 
'^ word-deafness^^  or  '•'■  word-'blindnessy  The  patient 
may  also  lose  the  power  of  recognizing  tunes,  or  of 
reading  musical  notes. 

It  is  rare  to  find  word- deafness  or  word-blindness 
without  other  affection  of  speech. 

4.  Kussmaul  gives  two  other  divisions  of  speech  dis- 
turbance which  are  closely  allied,  parapJiasia,  and 
agrammatism  or  aTcatapJiasia.  The  former  is  "the 
inability  to  properly  connect  word-images  and  the  cor- 
responding conceptions,  so  that,  instead  of  the  ones 
corresponding  to  the  sense,  misplaced  or  entirely  in- 
comprehensible word-images  present  themselves  "  ;  the 
latter  is  "the  inability  to  form  words  grammatically 
and  to  arrange  them  in  sentences  syntactically." 

These  peculiar  defects  of  speech  may  accompany 
ordinary  amnesic  or  ataxic  aphasia ;  they  rarely  occur 
alone.  It  may  be  convenient  to  retain  the  term  para- 
phasia, which  is  the  more  frequent  of  these  two  forms 
of  disturbance, 

5.  There  may  be  entire  loss  both  of  power  to  com- 
prehend what  is  said  and  of  the  power  of  expressing 
thought. 

The  lesions  which  cause  these  different  forms  of  dis^ 
turbance  of  speech  are  situated  in  the  vicinity  of  the 
posterior  part  of  the  third  frontal  convolution,  the 
island  of  Reil,  and  the  first  temporal  convolution,  or 
in  the  white  meduUary  substance  just  below  these  parts, 
or  in  the  course  of  the  motor  fibers  leading  to  the  vocal 
organs.  The  amnesic  aphasia  depends  on  lesion  of  the 
posterior  part  of  the  third  frontal  convolution  and  the 
island  of  Reil  near  that  spot,  or  the  white  substance 


DISTURBANCES  OF  SPEECH.  49 

immediately  below  ;  anarthria  depends  upon  interrup- 
tion of  tlie  centrifugal  fibers  passing  to  the  vocal  organs  ; 
word-deafness  and  word-blindness  occur  when  there  is 
lesion  of  certain  portions  of  the  auditory  or  visual  cen- 
ters. The  exact  seat  of  these  changes  is  not  yet  well 
determined.  Paraphasia  is  found  in  lesion  of  the 
island  of  E,eil,  the  adjacent  parts  of  the  first  temporal 
convolution,  or  the  commissural  white  fibers  immedi- 
ately below. 

In  all  forms  of  speech  disturbance  the  lesion  is  found, 
in  the  great  majority  of  cases,  on  the  left  side,  and  is 
associated  generally  with  more  or  less  fully  developed 
right  hemiplegia.  In  left-handed  persons  the  lesion  is 
usually  on  the  right ;  there  is  left  hemiplegia.  In  a 
few  cases  this  rule  is  not  observed. 

When  the  centrifugal  fibers  are  destroyed  near  the 
base  of  the  brain,  in  the  cerebral  peduncles,  iDons,  or 
medulla,  there  may  be  anarthria  with  either  right  or 
left  hemiplegia ;  such  cases  do  not  follow  the  above 
rule,  and  it  may  be  that  in  some  of  the  anomalous  cases 
the  distinction  between  true  aphasia  and  ataxic  aphasia 
or  anarthria  has  not  been  sufficiently  noticed. 
4 


CHAPTEE  III. 

DISEASES    OF   THE   MEMBEANES. 

ViRCHOW,  Das  Haematom  der  Dura  Mater.  Verhandl.  d.  phys. 
med.  Gesell.  in  Wiirzb.,  1857,  vii,  p.  134.— Hijguenin,  in  Ziems. 
sen's  Cyclopaedia,  vol.  xii. — GtRIESINGER,  W.,  Haematom  der  Dura 
Mater.  Ai^ch.  d.  Heilkunde,  3.  Bd.,  1.  H.— Kremiansky,  Jacob, 
Ueber  die  Pachymeningitis  interna  haeniorrhagica  bei  Menschen 
und  Hunden.  Virch.  Arch.,  42,  1868,  pp.  129  and  321.— Dujar- 
DIN  Beaumetz,  a  Lecture  on  the  Treatment  of  Meningitis.  New 
York  Med.  Journal,  Aug.  11,  1883,  p.  141.— Bertalot,  H.,  Ueber 
Meningitis  tuberculosa  bei  Kindern.  Jahrbuch  f.  Kinderheil- 
Jcunde,  ix,  1876,  p.  227.— Seitz,  Johannes,  Die  Meningitis  tuber- 
culosa der  Erwacbsenen,  Berlin,  1874. —Dawson,  Y.,  Tubercular 
Meningitis  in  an  Infant  ;  Death  ;  Necropsy  ;  Remarks.  London 
Lancet,  April  12,  1884,  p.  660.  • 

PACHYMENINGITIS. 

Inflammation  of  the  dura  mater  is  not  very  common 
as  an  independent  disease.  The  dura  mater  is  composed 
of  two  lameUse  which  are  loosely  united  with  each  other  ; 
either  of  these  may  be  the  seat  of  disease  ;  hence  arise 
external  and  internal  pachymeningitis. 

EXTERNAL   PACHYMENINGITIS 

is  caused  by  disease  of  adjacent  bony  structures  or  by 
injuries.  The  symptoms  are  so  combined  with  those 
arising  from  the  primary  affection,  and  the  indications 
for  treatment  depend  upon  the  nature  of  that  affection 
to  such  a  degree,  that  it  is  not  necessary  to  delay  longer 
on  this  variety  of  the  disease. 


FA  GETMENmGITIS.  5 1 

INTERNAL   H^MOEKHAGIC   PACHYMENINGITIS. 

There  are  two  different  views  as  to  tlie  origin  of 
hsemorrhagic  pachymeningitis :  one  proposed  by  Vir- 
chow  and  generally  adopted,  according  to  which  there 
is  first  a  congestion  of  the  dura  mater,  which  gives  rise 
to  a -thin  membrane  on  its  inner  surface;  under  this 
membrane  occur  haemorrhages ;  the  clot  becomes  or- 
ganized and  forms  a  membrane  of  greater  or  less  thick- 
ness, under  which  more  blood  is  poured  out,  and  this 
process  may  be  frequently  repeated. 

Huguenin  states  that  he  has  not  been  able  to  dis- 
cover any  initial  inflammation  of  the  dura  mater,  nor 
any  dilatation  of  the  middle  meningeal  artery.  He 
says  the  first  stage  is  simply  an  extravasation  of  blood, 
which  becomes  organized,  forming  a  false  membrane, 
and  from  this  arise  new  haemorrhages.  The  difference 
between  Yirchow  and  Huguenin  relates  only  to  the 
first  stage  of  the  disease. 

The  brain  may  be  much  compressed,  and,  as  the 
affection  occurs  chiefly  in  patients  suffering  from  other 
diseases,  the  changes  due  to  those  diseases  will  be 
found. 

Etiology. — The  larger  proportion  of  patients  are 
advanced  in  age  ;  many  have  been  hard  drinkers  ;  some- 
times an  acute  disease  immediately  precedes  the  menin- 
geal affection  ;  the  insane,  or  those  suffering  from  other 
cerebral  disease,  may  be  attacked.  Huguenin  finds  a 
cause  in  cerebral  atrophy,  whether  the  result  of  old 
age,  alcoholism,  or  other  cerebral  changes  ;  he  also  be- 
lieves the  blood  comes  from  the  veins  of  the  pia  mater. 
Injuries  have  been  sometimes  the  cause. 

Symptoms. — Many  times  the  hsematoma  gives  rise 
to  no  characteristic  symptoms. 

Headache  is  the  most  common  symptom  ;  this  may 
be  severe,  or  there  may  simply  be  a  sense  of  heaviness 
or  pressure.  Sometimes  the  patient  has  a  sensation  as 
if  something  moved  back  and  forth  in  his  head,  which 


52  DISEASES  OF  THE  BRAIK 

Griesinger  refers  to  the  sensation  caused  by  a  large 
cyst  moving  with  the  motion  of  the  head.  This  is, 
however,  felt  under  other  circumstances  where  there 
can  be  no  cyst,  and  therefore  is  not  pathognomonic.  - 

When  the  haemorrhage  first  occurs,  there  will  be  the 
symptoms  of  meningeal  haemorrhage,  more  or  less  fully 
marked  ;  the  symptoms  of  cerebral  compression,  aboli- 
tion or  dullness  of  intellect ;  motor  disturbance,  irregu- 
lar spasmodic  motions,  contractures,  or  loss  of  power, 
sometimes  paralysis  ;  slowness  of  pulse,  sometimes  with 
irregularity  ;  the  opposite  pupil  more  dilated,  the  cor- 
responding pupil  contracted. 

These  symptoms  may  be  very  marked  if  the  haemor- 
rhage is  large,  and  the  paralysis  may  even  be  bilateral, 
though  one  side  is  affected  first,  the  other  later. 

The  patient  regains  after  some  days  his  former  con- 
dition of  health,  or  may  remain  dull,  drowsy,  and 
paretic  ;  usually  the  headache  persists.  After  a  longer 
or  shorter  interval,  another  attack  occurs.  With  the 
repetition  of  the  phenomena  the  diagnosis  becomes 
more  certain. 

DiAGisrosis. — When  the  haemorrhage  is  insignificant, 
a  correct  diagnosis  may  be  impossible ;  when  the  haem- 
orrhage is  large,  the  symptoms  are  those  of  meningeal 
haemorrhage,  and  it  is  only  by  waiting  for  the  subse- 
quent course  of  the  case  to  develop  that  a  diagnosis  can 
be  made. 

PEOG]srosis. — The  disease  is  always  serious  and  gen- 
erally fatal ;  recovery  may  occur.  Griesinger  reports  a 
case  in  which  the  haemorrhagic  cyst  was  found  nine 
years  after  the  attack,  the  patient  having  recovered  his 
health.  Often,  however,  the  disease  with  which  the 
pachymeningitis  is  associated  is  one  which  renders  re- 
covery hopeless. 

Teeatmeistt. — The  treatment  should  have  reference 
to  preventing  the  haemorrhage,  to  favoring  absorption. 
Quiet,  rest,  cold  to  the  head  without  intermission, 
leeches  behind  the  ears,  and  a  light  diet,  may  fulfill  the 


INFLAMMATION  OF  TEE  PI  A  MATEB.  53 

first  indication  immediately  after  the  acute  attack.  In 
the  interval  everything  which  would  favor  increase  of 
blood-pressure  should  be  avoided.  Iodide  of  potas- 
sium and  mercury  in  moderate  amount  may  be  used. 

INFLAMMATION   OF   THE   PI  A   MATER. 
LEPTOMENINGITIS. 

By  cerebral  meningitis,  inflammation  of  the  pia  ma- 
ter is  commonly  understood.  Cerebral  meningitis  may 
be  either  sim^Dle  or  it  may  be  dependent  upon  the  de- 
posit of  tubercles.  The  latter  is  the  more  frequent, 
and  the  disease  is  much  more  common  with  children 
than  with  adults.  In  adults,  considering  all  cases,  sim- 
ple meningitis  is  more  common  than  among  children  ; 
indeed,  it  is  so  rare  in  childhood  that  some  authors 
have  denied  its  existence. 

iETioLOGiY. — N'on-tubercular  meningitis  may  be  pri- 
mary or  secondary.  When  primary,  it  is  often  impossi- 
ble to  discover  the  cause ;  at  other  times  there  has  been 
exposure  to  the  sun,  mental  anxiety  or  overwork,  great 
physical  exertions,  the  influence  of  cold  and  dampness ; 
alcoholic  excess  has  also  been  mentioned  as  a  cause. 

Meningitis  may  be  secondary  to  disease  of  the  bones 
enveloping  the  brain,  as  the  temporal  bone  in  diseases 
of  the  ear.  An  obstinate  or  long-persisting  otorrhoea 
should  therefore  never  be  neglected.  Never  neglect 
purulent  otorrhoea  under  the  impression  that  it  is  com- 
paratively harmless. 

Injuries  to  the  cranial  bones  and  fractures  may  give 
rise  to  caries  and  to  meningitis  ;  so  also  may  syphilitic 
disease  of  the  bones,  and  some  intra-cranial  affections, 
as  tumors  and  abscesses. 

Meningitis  may  be  secondary  to  acute  diseases,  as 
pneumonia,  pleurisy,  cardiac  lesions,  eruptive  fevers, 
erysipelas  of  the  head,  rheumatism,  dysentery,  perito- 
nitis, and  diphtheria  ;  Bright's  disease  is  occasionally 
complicated  with  meningitis. 


54  DISEASES  OF  TEE  BRAIN. 

Pathological  Anatomy. — The  lesion  may  occupy 
either  the  base  of  the  brain  or  the  convexity,  or  it  may 
be  limited  to  a  circumscribed  area  only.  The  smaller 
vessels  are  distended  with  blood,  the  large  veins  are 
full.  There  is  more  or  less  serum  exuded  from  the  ves- 
sels into  the  meshes  of  the  pia  mater.  Along  the  ves- 
sels are  collections  of  pus,  mixed  with  fibrinous  exuda- 
tion. If  this  is  in  comparatively  small  amount,  it  is 
found  only  in  the  sulci  ;  otherwise  it  may  be  spread  over 
the  convexity.  At  the  base  of  the  brain  it  is  collected 
also  in  the  depressions,  by  preference  around  the  pons ; 
under  the  posterior  lobe,  near  the  crura  cerebri ;  be- 
tween the  crura  ;  and  around  the  optic  nerves.  This 
exudation  is  not  free  fluid,  but  is  contained  in  the 
meshes  of  the  pia  mater,  which  is  swollen,  or  a  fibri- 
nous exudation  may  contain  pus  and  serum  ;  it  may  be 
large  in  amount,  especially  at  the  base,  and  the  nerves 
may  be  surrounded  by  a  thick,  comparatively  firm 
fibro-purulent  sheath. 

In  very  chronic  cases  there  may  be  found  thickened 
patches  in  the  pia  mater,  composed  of  fibrous  tissue 
among  whose  fibers  the  microscope  shows  pus- cells. 

In  cases  of  moderate  duration  the  membranes,  on 
being  strijDped  off,  may  carry  away  portions  of  the  gray 
substance. 

Sometimes  the  ventricles  are  distended  with  serum ; 
but  this  is  less  common  than  in  tubercular  meningitis. 
If  they  are  distended,  their  lining  membrane,  the  epen- 
dyma,  is  found  thickened  or  covered  with  granulations, 
and  it  may  be  softened. 

Symptoms. — The  commencement  of  the- disease  is 
usually  acute.  Occasionally,  for  a  few  hours  or  days, 
there  are  headache,  vomiting,  and  dizziness  ;  but  these 
prodromata  are  not  common  ;  there  is  not,  as  a  rule, 
the  preceding  ill-health  which  is  so  often  seen  in  tu- 
bercular meningitis. 

The  initial  symptom  is  a  severe  headache  ;  occasion- 
ally a  chill,  soon  followed  by  vomiting ;  the  temperature 


INFLAMMATION^  OF  THE  PIA  MATEE.  65 

rises  quickly,  even  to  104°  ;  tlie  pulse  is  rapid  ;  there  is 
delirium  ;  sometimes  there  are  convulsions ;  toward  the 
latter  part  of  the  first  stage  motor  disturbances  appear, 
either  paralysis  or  contractions.  The  second  stage  is 
characterized  by  coma  and  the  destruction  of  all  the 
vital  powers. 

The  duration  of  the  disease  is  from  a  few  hours  to 
several  days.  When  the  disease  is  secondary  to  some 
other  affection,  the  duration  may  be  very  short.  When 
a  large  part  of  the  convexity  is  affected,  life  is  usually 
not  prolonged  beyond  a  few  days  ;  when  the  disease 
is  limited  to  the  base,  the  patient  may  live  several 
w^eeks. 

If  the  patient  lives  but  a  few  days,  the  initial  symp- 
toms will  be  quickly  followed  by  the  more  serious,  and 
the  final  stage  will  almost  immediately  succeed  the 
earlier  symptoms.  If  the  disease  is  protracted,  there  is 
a  more  regular  progression,  and  it  may  be  possible  even 
to  divide  the  disease  into  stages. 

Headache  is  the  most  constant  symptom,  and  is  no- 
ticeable so  long  as  consciousness  continues,  and  even 
during  delirium ;  or  in  a  child  too  young  to  speak,  the 
knitted  brows,  the  restless  motion  of  the  head,  the 
hands  carried  to  the  head,  the  moaning  and  crying, 
clearly  show  that  there  is  headache.  The  pain  is  more 
frequently  general,  but  sometimes  is  confined  to  the 
frontal  or  occipital  regions. 

The  temperature  is  high  at  the  beginning  of  the  dis- 
ease. When  there  is  meningitis  of  the  convexity,  the 
temperature  remains  high,  and  shows  less  variation 
than  when  the  base  alone  is  affected. 

The  pulse  may  be  at  first  rapid ;  subsequently  it  be- 
comes less  rapid,  and  fluctuates  independently  of  the 
temperature ;  toward  the  close  of  life  it  may  become 
excessively  rapid  again,  but,  if  there  is  compression 
of  the  brain  by  exudations,  it  may  fall  even  as  low 
as  50. 

Respiration  is  not  especially  affected  in  the  earlier 


56  DISEASES  OF  TEE  BRAIN. 

stages,  excepting  that  it  may  be  very  rapid  in  children  ; 
but  toward  the  close  of  life  it  may  be  irregular,  and  the 
peculiar  rhythm,  which  has  been  named  Cheyne- Stokes 
respiration,  may  be  observed.     (See  page  10.) 

Vomiting  may  be  an  early  symptom ;  at  first  the 
ingesta  are  vomited,  later  it  is  bilious.  Sometimes  the 
vomiting  does  not  appear  until  a  later  period  of  the 
disease.  There  are  very  few  cases  in  which  vomiting 
does  not  occur.  The  appetite  frequently  does  not  suf- 
fer, and  the  patients  take  food  readily,  though  they 
soon  reject  it  again.  The  vomiting  is  often  very  obsti- 
nate. 

Constipation  almost  invariably  is  extreme,  and  it  is 
sometimes  nearly  impossible  to  obtain  a  motion. 

Delirium  is  one  of  the  earlier  symptoms  when  the 
convexity  is  affected,  beginning  suddenly  with  delu- 
sions or  hallucinations ;  the  patients  may  try  to  rise 
and  wander  about,  or  they  may  become  furious  at  re- 
straint. In  other  cases  the  delirium  shows  itself  at 
first  only  as  the  patient  is  falling  asleep ;  it  is  more 
quiet,  muttering,  or  talkative. 

In  meningitis  of  the  base,  delirium  is  less  constant ; 
but,  when  the  convolutions  adjacent  to  the  base  are 
affected,  it  may  be  present. 

In  the  later  stages  the  mental  powers  are  destroyed, 
the  patient  passes  into  coma,  from  which  there  may 
possibly  be  a  slight  awakening  before  death  ;  but  this 
is  less  common  than  in  tubercular  meningitis. 

Convulsions  are  almost  always  present  in  meningitis 
of  the  convexity.  When  the  base  alone  is  affected, 
there  is  generally  at  least  local  spasmodic  action  of 
some  of  the  muscles  supplied  by  the  cranial  nerves. 

Contractions  also  occur ;  there  is  rigidity  of  the 
neck,  the  muscles  of  the  face  may  be  affected,  or 
there  may  be  strabismus.  It  is  not  common  to  have 
permanent  contraction  of  the  limbs ;  when  they  are 
affected,  there  is  usually  partial  flexion.  Attacks  of 
opisthotonos,  with  tonic  contraction  of  the  extensors 


INFLAMMATION  OF  TEE  PI  A  MATER  57 

of   tlie    limbs,   may  be   present  and    last  for    a  few 
minutes. 

The  abdomen  is  less  frequently  retracted  than  in 
tubercular  meningitis  ;  yet  this  is  sometimes  seen,  espe- 
cially when  the  disease  is  chiefly  at  the  base  of  the 
brain. 

That  disturbance  of  the  vaso-motor  nerves  which 
leads  to  the  easy  production  of  the  tdche  cerebrale 
is  less  common  in  simple  meningitis  than  in  tuber- 
cular. 

The  patient  gradually  passes  into  a  state  of  coma, 
the  delirium  alternates  with  stupor,  the  convulsions 
diminish  in  frequency,  the  contractions  are  now  re- 
laxed, again  reappear,  until  finally  coma  is  fully  estab- 
lished ;  then  there  is  dilatation  of  the  pupils,  relaxa- 
tion of  the  sphincters,  the  pulse  becomes  slow  and 
irregular,  but  the  temperature  rises,  the  insensibility  is 
profound,  and  the  patient  dies  without  a  struggle. 
Death  may,  however,  occur  at  an  earlier  stage  during 
the  delirium  and  convulsions. 

The  headache  is  explained  by  the  affection  of  the 
membranes,  by  the  exudation  and  fullness  of  the  ves- 
sels. Leucocytes  wander  from  the  vessels  into  the  cor- 
tical layers  of  the  brain,  the  circulation  is  interfered 
with,  there  is  irritation  of  the  nerve-cells ;  hence  the 
delirium,  the  convulsions.  If  the  cortex  is  affected, 
these  are  more  marked  and  more  general ;  if  the  base 
only  is  affected,  there  is  less  probability  of  delirium,  and 
the  convulsions  and  contractions  are  more  likely  to 
affect  the  muscles  supplied  by  the  cranial  nerves.  From 
over-stimulation  may  follow  exhaustion ;  hence  the 
convulsions  intermit.  When  the  disease  has  produced 
destruction  of  the  nerve-cells,  which  is  rare,  or  when 
effusion  into  the  ventricles  has  produced  compression 
of  the  brain,  or  the  exhaustion  has  become  extreme, 
the  last  stage  sets  in,  and  there  is  coma.  This  sketch 
of  an  explanation  of  the  symptoms  is  rather  brief,  but, 
by  keeping  in  mind  the  physiological  relations  of  the 


58  DISEASES  OF  THE  BE  Am. 

parts  affected,  it  will  often  be  easy  to  explain  the  vary- 
ing symptoms. 

When  meningitis  occurs  in  the  course  of  acute  dis- 
eases or  as  the  result  of  injuries,  necrosis  of  bone,  etc., 
the  symptoms  are  less  clearly  defined.  The  previous 
primary  disease  obscures  the  beginning  of  the  menin- 
geal affection.  (For  a  complete  discussion  of  the  pos- 
sible variations,  Ziemssen's  "  Cyclopaedia,"  vol.  xii,  may 
be  consulted.) 

After  acute  meningitis  certain  symptoms  remain ; 
there  is  a  chronic  thickening  and  change  which  is  per- 
manent. 

Local  changes  in  the  membranes  and  cerebral  cor- 
tex may  give  rise  to  spasms  of  a  few  muscles  or  a 
limb,  which  may  spread  to  all  the  limbs,  becoming  gen- 
eral convulsions.  Spasms  confined  to  one  set  of  mus- 
cles, or  which  always  begin  in  the  same  muscles,  are 
characteristic  of  cortical  changes.  The  situation  of  the 
disease  can  be  localized  in  the  motor  centers  corre- 
sponding with  the  affected  limb. 

When  the  motor  center  is  destroyed,  there  will  then 
be  paralysis  of  the  limb  instead  of  spasm. 

Meningitis  is  present  in  the  beginning  of  these 
cases,  but  soon  the  brain- substance  is  affected ;  there 
is  then  really  encephalitis.  Many  times  syphilis  is 
the  cause  of  these  local  changes  in  the  membranes 
and  cortex. 

Diagnosis. — The  diagnosis  from  tubercular  menin- 
gitis will  be  considered  under  the  latter  disease.  Cere- 
britis  commences  less  suddenly,  and  the  febrile  symp- 
toms are  less  severe  ;  the  symptoms  are  generally  more 
circumscribed. 

The  eruptive  fevers  may  be  complicated  with  men- 
ingitis, but  it  is  only  occasionally  that  this  is  so ;  ty- 
phoid fever  is  more  frequently  thus  complicated  than 
the  others.  The  diagnosis  is  rendered  more  diflBcult 
because  head  symptoms  occur  without  meningitis.  The 
delirium  is  more  active  when  there  is  meningitis,  the 


INFLAMMATION  OF  THE  PIA  MATEE.  59 

headacTie  is  more  severe,  and  there  are  more  frequently 
convulsions. 

The  course  of  the  pulse  and  temx3erature  is  less  regu- 
lar than  is  normal  in  the  eruptive  fevers.  The  charac- 
ter of  the  delirium,  the  sudden  change  in  the  tempera- 
ture and  pulse,  a  sudden  increase  of  headache,  the 
character  of  the  convulsions — these  data  will  aid  in 
diagnosis,  but  there  will  often  be  a  doubt. 

Cerebral  symptoms  during  the  course  of  acute  rheu- 
matism are  not  always  due  to  meningitis ;  frequently 
an  autopsy  shows  no  change  of  the  membranes  ;  occa- 
sionally, however,  there  is  inflammation.  The  diagno- 
sis is  extremely  difiicult,  and  usually  the  patient  dies 
without  a  decision  being  reached.  Yet  more  difficult 
are  those  cases  in  which  severe  cerebral  symptoms  occur 
on  the  first  outbreak  of  rheumatic  fever  before  the  joints 
are  affected.  These  cases  are  rare  ;  sometimes  the  cere- 
bral symptoms  subside,  and  the  articular  phenomena 
appear  to  clear  up  the  diagnosis. 

Once  in  a  while  pericarditis  is  accompanied  with 
delirium  and  other  cerebral  phenomena ;  there  is  not 
necessarily  meningitis  ;  the  primary  disease  is  shown  by 
physical  examination,  and  is  the  more  important  in 
treatment. 

The  coma  after  epilepsy  and  in  the  course  of  Bright's 
disease  may  be  recognized  by  the  aid  of  the  early  his- 
tory, the  thermometer,  and  a  careful  examination  of 
the  urine,  keeping  in  mind,  however,  that  albumen  may 
be  present  in  the  urine  passed  after  an  epileptic  attack 
or  in  meningitis  ;  the  presence  of  marked  oedema,  asci- 
tes, or  other  serous  effusions  would  also  aid  in  diagno- 
sis. If  the  previous  history  can  not  be  learned,  a  diag- 
nosis may  be  impossible.  It  should  be  kept  in  mind 
that  meningitis  may  arise  during  the  course  of  Bright's 
disease,  as  purulent  inflammation  of  other  serous  mem- 
branes may  occur. 

The  possibility  of  poisoning  should  be  remem- 
bered. 


60  DISEASES  OF  TEE  BEAm. 

The  diagnosis  from  alcoholism  will  be  considered 
Tinder  the  latter  affection. 

PeogjS^osis. — The  prognosis  is  very  unfavorable  ;  a 
recovery  is  rare,  and  is  almost  never  complete.  The  pa- 
tient, if  life  is  not  lost,  is  liable  to  have  headaches,  to 
have  partial  loss  of  memory  and  diminished  intellectual 
power.  "When  a  natural  sleep  takes  the  placf'.  of  coma 
and  the  patient  awakes  without  fever,  without  paraly- 
sis, with  a  clear  mind,  though  acting  slowly,"  the  prog- 
nosis is  favorable. 

Tkeatmei^t. — When  the  disease  is  uncomplicated, 
and  the  patient  is  seen  at  the  beginning  of  the  attack, 
the  treatment  can  be  vigorous,  and  there  should  be  no 
delay.  If  the  patient's  strength  justifies,  general  bleed- 
ing is  proper.  If  the  patient  is  feeble,  leeches  may  be 
applied  over  the  mastoid  bones ;  blood  may  be  drawn 
by  cups  from  the  nape  of  the  neck.  Cold  to  the  head, 
uninterruptedly,  and  smart  purgation,  are  to  be  em- 
ployed. Some  advise  blistering  the  scalp ;  but  this  is 
of  doubtful  value. 

In  this  disease,  as  in  others,  a  high  temperature 
may  be  met  by  cold  baths,  repeated  as  the  tempera- 
ture again  rises,  or  a  lukewarm  bath,  and  showering 
the  head  with  cold  water  has  been  advised.  Of  course, 
the  patient's  strength  should  be  taken  into  account  and 
all  precautions  taken,  as  in  other  acute  diseases.  Among 
drugs  to  lower  temperature  are  salicylic  acid  and  qui- 
nine in  large  doses  ;  antipyrin,  in  doses  of  thirty  or  forty 
grains,  repeated,  if  necessary,  in  an  hour  or  two,  may 
lower  the  temperature.  Iodide  of  potassium  in  large 
doses,  repeated  at  short  intervals,  is  of  great  value. 
If  there  is  a  suspicion  of  syphilis,  mercurial  inunctions 
should  be  used  ;  this  has  been  strongly  urged  by  some, 
even  when  there  is  no  reason  to  suspect  syphilis.  Er- 
got has  been  recommended  ;  but  its  value  is  doubtful. 

The  headache  and  delirium  are  exhausting ;  they 
should  be  met  by  chloral  and  bromide  of  potassium  in 
large  doses,  from  twenty  to  fifty  grains  of  each  (one  and 


TUBERCULAR  MENINGITIS.  61 

a  half  to  three  grammes),  repeated  after  half  an  hour  or 
an  hour  if  necessary.  These  can  be  given  by  enemata 
if  the  stomach  will  not  retain  ingesta.  Small  closes  of 
chloral,  under  fifteen  grains  (one  gramme),  are  of  no 
value,  but,  even  when  frequently  repeated,  often  seem  to 
increase  the  delirium.  Subcutaneous  injections  of  mor- 
phia may  be  of  great  value  to  check  convulsions  and 
stop  the  obstinate  vomiting. 

The  patient's  strength  should  be  sustained  by  a 
proper  diet ;  if  there  is  much  vomiting,  by  nutrient 
enemata.  Milk  two  parts,  and  lime-water  one  part,  in 
very  small  amounts,  beginning  with  a  teaspoonf  ul  every 
half  hour,  is  sometimes  most  valuable  in  vomiting. 
Sometimes  it  is  necessary  to  give  the  stomach  entire 
rest. 

Trousseau  speaks  most  discouragingly  of  all  treat- 
ment, and  emphatically  disapproves  of  all  active  and 
depressing  measures.  He  says  that  in  the  two  cases 
of  recovery  which  he  had,  Nature  deserves  the  credit 
rather  than  his  art. 


TUBERCULAR   MENIJfGITIS. 

Pathological  Aisr atomy, — This  disease,  as  is  well 
known,  consists  in  a  more  or  less  extensive  growth  of 
miliary  tubercles  in  the  pia  mater  and  the  inflammation 
excited  thereby.  In  a  large  majority  of  cases  the  ba- 
cilli of  tuberculosis  are  carried  by  the  blood  to  the  spot 
where  they  develop  ;  then  the  tubercles  form  upon  or 
within  the  vessels,  and  the  normal  epithelial  cells  un- 
dergo a  change  by  which  a  large  number  of  smaller, 
more  round,  cells  are  formed  by  subdivision,  until  a 
small  nodule  is  formed,  by  the  continued  growth  of 
which  the  vSssel  is  closed,  and  then  fatty  degeneration 
of  these  cellular  elements  gives  rise  to  the  yellow,  case- 
ous centers  which  are  seen  in  the  larger  nodules.  These 
growths  are  found,  not  merely  upon  the  vessels  of  the 
membranes,  but  also  on  those  which  enter  the  cortex  of 


62  DISEASES  OF  THE  BRAIN. 

the  brain.  The  irritation  of  these  nodules,  and  their 
interference  with  the  normal  nutrition  of  the  mem- 
branes, give  rise  to  inflammation  ;  hence  there  are  add- 
ed to  the  miliary  tubercles  the  injection  and  exuda- 
tions, the  fibro-purulent  deposits  of  meningitis. 

When  the  tubercles  are  many  and  of  moderate  size, 
it  is  easy  to  recognize  them  ;  but  when  small  and  few  in 
number,  a  careful  examination  will  be  necessary. 

The  inflammation  excited  by  these  deposits  of  tuber- 
cle is  not  confined  exclusively  to  the  vicinity  of  the  mor- 
bid growths,  though  it  is  generally  more 'marked  there. 
Pus  may  be  found  at  a  distance,  especially  along  the 
course  of  the  vessels. 

The  ventricles  are  frequently  filled  with  serum,  some- 
times so  distended  as  to  cause  compression  of  the  brain 
and  flattening  of  the  convolutions. 

The  pathological  changes  are  fully  considered  in 
treatises  upon  pathological  anatomy  and  upon  chil- 
dren's diseases. 

In  the  vast  majority  of  cases  there  are  tubercles  or 
cheesy  deposits  in  other  organs,  whence  the  bacillus  is 
carried  to  the  brain. 

When  there  seems  to  be  an  exception,  the  question 
arises  whether  the  disease  may  not  have  existed  undis- 
covered. 

Etiology. — Tubercular  meningitis  is  much  more 
common  in  early  life — between  two  and  seven  years. 
Among  adults  it  is  the  more  frequent  between  the  ages 
of  twenty  and  thirty  or  thirty-five.  Seitz  found  that,  in 
every  thousand  deaths  among  adults,  tubercles  were 
present  in  the  pia  in  fifteen  cases.  Males  are  more  fre- 
quently affected  than  females. 

As  tubercular  meningitis  is  generally  secondary  to 
tubercular  or  cheesy  deposits  elsewhere,  air  those  influ- 
ences which  favor  the  development  of  such  changes  in 
other  organs  will  act  as  predisposing  causes  of  this 
disease. 

Symptoms. — Many  times  there  has  been  a  gradual 


TUBERCULAR  MENINGITIS.  63 

failure  of  health  preceding  the  outbreak  of  the  symp- 
toms strictly  due  to  the  meningeal  affection.  The  pre- 
ceding disease  has  undermined  the  general  health.  As 
the  tubercles  alone  probably  have  little  influence  in 
producing  the  symptoms,  which  appear  only  when  in- 
flammation arises,  it  is  not  possible  to  determine  how 
long  the  morbid  growths  have  existed.  Whether  some 
of  the  earlier  symptoms,  as  heaviness,  languor,  change 
of  disposition,  occasional  headaches,  are  caused  by  the 
tubercular  deposit,  or  by  inflammation  localized  around 
these,  is  not  absolutely  certain,  but  probably  by  the 
latter. 

Sometimes,  owing  to  the  primary  disease,  it  is  diffi- 
cult to  recognize  the  beginning  of  the  meningeal  affec- 
tion ;  at  other  times  the  onset  is  as  sudden  as  in  simple 
meningitis.  There  may  be  a  chill,  but  headache  is 
more  frequently  the  initial  symptom.  In  children,  con- 
vulsions may  occur  early.  Vomiting  occurs  sooner  or 
later  in  almost  all  cases,  but  may  cease  after  a  few 
days ;  there  is  constipation.  There  may  be  general 
hypergesthesia  of  the  skin,  also  an  over-sensitiveness  to 
noise  and  to  light.  The  patient  will  perhaps  bury  his 
face  in  the  pillow  to  shield  his  eyes  from  the  faintest 
ray  of  light. 

The  temperature  is  very  irregular.  Sometimes  there 
is  high  fever  at  the  beginning,  but  less  regularly  so  than 
in  simple  meningitis.  Not  unfrequently  the  tempera- 
ture is  normal  for  several  days ;  then  its  course  is  irregu- 
lar. A  very  high  temperature  is  not  often  found  until 
toward  the  close  of  life.  The  pulse  also  varies,  but 
does  not  vary  with  the  changes  of  temperature. 

Convulsions  may  occur  in  the  later  stages  of  the  dis- 
ease, and  partial  convulsions — as  of  the  muscles  of  the 
face,  of  the  eyes,  or  of  mastication — are  seen  in  many 
cases,  producing  contortions  of  the  face,  strabismus, 
etc.  The  head  may  be  drawn  back,  or  at  least  the  neck 
be  stiff ;  the  abdomen  may  be  retracted.  The  pupils 
may  react  imperfectly  or  be  unequal.    Paralysis  of  one 


64  DISEASES  OF  TEE  BRAIW. 

or  more  limbs,  as  well  as  of  certain  muscles  supplied  by 
cranial  nerves,  occur  after  a  few  days.  The  tache  cere- 
brale  can  very  generally  be  produced. 

The  mental  symptoms  are  sometimes  delayed  until 
a  late  stage,  sometimes  appear  early  ;  irritability,  mood- 
ishness,  fretfulness,  and  lack  of  mental  vigor,  may  be 
among  the  earlier  phenomena.  Delirium  is  common,  es- 
pecially on  falling  asleep  ;  it  is  not  generally  very  vio- 
lent. Toward  the  close  of  the  disease  all  mental  func- 
tion is  abolished,  there  is  complete  coma ;  then  the 
more  active  symptoms — as  spasms,  contractions,  cries, 
restlessness — cease.  The  temperature  generally  rises 
quickly,  once  in  a  while  becomes  lower.  The  pulse 
may  be  very  slow.  Respiration  becomes  irregular,  the 
Cheyne-Stokes  respiration  may  appear,  and  soon  the 
patient  dies.  A  short  time  before  death  intelligence 
may  return  ;  there  seems  to  be  a  very  great  improve- 
ment, which  may  well  deceive  the  friends,  but  the  phy- 
sician should  be  on  his  guard. 

Optic  neuritis  is  quite  common  in  tubercular  menin- 
gitis, unless  the  disease  is  confined  to  the  convexity. 
The  neuritis  is  not  often  intense  ;  is  sometimes  so  slight 
as  to  not  be  easily  recognized  ;  it  is  rarely  accompanied 
with  haemorrhages.     Both  eyes  are  affected. 

It  has  been  the  custom  to  divide  the  progress  of  the 
disease  into  three  stages :  1.  Irritation ;  2.  Pressure ; 
3.  Paralysis  or  coma. 

Occasionally  these  stages  are  well  defined,  but  more 
frequently  they  run  into  one  another,  and  the  symptoms 
occur  with  so  little  regard  to  orderly  succession,  that  it 
is  not  possible  to  define  the  various  stages.  Rather 
than  to  describe  the  disease  thus,  I  have  preferred  to 
give  a  general  description,  which,  it  seems  to  me,  more 
nearly  corresponds  with  what  is  seen  in  common  prac- 
tice. 

The  following  explanation  of  the  symptoms,  con- 
densed from  Huguenin,  will  assist  to  a  better  under- 
standing of  the  disease :  The  earlier  prodromal  symp- 


TUBERCULAR  MENINGITIS.  65 

toms,  if  there  are  any,  may  depend  upon  disturbance 
of  the  nutrition  of  the  brain,  caused  by  the  tubercles, 
possibly  by  irregular  and  variable  irritation  of  the 
nerve-cells.  Inflammation*  of  the  pia  mater  is  excited 
by  the  tubercles  ;  the  cortex  is  affected  secondarily ; 
occasionally  slight  haemorrhages  occur.  The  mental 
symptoms  are  those  of  excitement  during  the  rise  of 
the  inflammation,  the  character  of  the  mental  disturb- 
ance varying  with  the  locality  of  the  inflammation,  as 
different  nerve-centers  are  affected.  The  hydrocephalic 
effusion  will  explain  the  symptoms  of  compression 
which  are  seen  toward  the  close  of  the  disease.  The 
convulsions  may  be  referred  to  irritation  of  nerve- 
centers  in  the  cortex  or  to  an  irritation  of  the  medulla 
oblongata,  the  latter  especially  if  the  convulsions  are 
general.  Rigidity  of  the  muscles  of  the  neck,  and  the 
weakness  and  peculiarities  of  gait,  are  not  easily  ex- 
plained, but  may  be  due,  not  simply  to  the  cerebral 
lesion,  but  rather  to  spinal  complications.  When  pa- 
ralyses of  individual  limbs  or  of  one  side  occur  early, 
there  is  usually  a  local  cause,  easily  recognized  at  the 
autopsy  (as  haemorrhage  or  local  softening).  When 
these  occur  late,  the  cause  may  escape  detection.  Local 
paralysis  of  individual  cranial  nerves  may  be  explained 
by  the  effusion  around  the  roots  of  these  nerves,  the 
neuritis  or  other  degenerative  changes  set  up  in  them. 

When  the  cortex  is  chiefly  or  exclusively  affected, 
mental  symptoms  will  predominate,  with  local  spasms 
and  paralyses  ;  when  the  base  is  chiefly  affected,  men- 
tal symptoms  may  be  almost  entirely  absent ;  general 
weakness,  general  spasms,  paralyses  of  cranial  nerves, 
and  at  length  hydrocephalus,  will  be  the  principal  symp- 
toms. 

Diagnosis. — The  first  question  is  naturally  whether 
there  is  meningitis  ;  the  second,  whether,  if  present,  it 
is  simple  or  tubercular.  The  following  enumeration  of 
the  more  important  symptoms  is  given  by  Seitz  :  ' '  Head- 
ache ;  vomiting ;  constipation  ;  absence  of  roseola  ;  stu- 


66  '     DISEASES  OF  TEE  BRAIK 

pefaction  ;  confusion  ;  delirium  ;  obstinacy  ;  carpliolo- 
gia  ;  stiffness  of  the  neck,  back,  or  muscles  generally  ; 
general  hypersesthesia ;  retracted  abdomen  ;  paralysis 
of  the  pupils,  eyelids,  eyes,  *of  the  face,  of  the  limbs ; 
trembling ;  twitching ;  convulsions  ;  old  phthisical  affec- 
tion of  the  lungs,  and  other  chronic  inflammatory,  sup- 
purating, and  caseous  processes  ;  duration  of  the  disease 
from  two  to  four  weeks  with  fatal  termination." 

The  diagnosis  from  simple  meningitis  is  not  by  any 
means  always  easy.  The  diagnosis  will  be  facilitated 
by  bearing  in  mind,  that  in  children  tubercular  menin- 
gitis is  much  the  more  common,  while  in  adults  simple 
meningitis  is  the  more  prevalent. 

The  condition  of  health  preceding  the  attack  is  an 
important  element  in  diagnosis.  The  tubercular  form, 
as  a  rule,  begins  less  acutely,  the  duration  is  longer,  and 
the  course  more  irregular. 

The  temperature  is  less  steady,  may  be  moderately 
elevated  only  for  a  few  days,  may  be  below  normal,  is 
rarely  very  high,  excepting  toward  the  close  of  life. 
In  simple  meningitis  the  temperature  is  higher  at  the 
commencement,  and  is  more  regular.  The  pulse  is  fre- 
quently slow  in  tubercular  meningitis,  and  does  not 
necessarily  follow  the  variations  of  the  temperature. 

Tubercular  meningitis  is  the  more  often  accompa- 
nied with  paralyses  of  the  cranial  nerves,  and  even  of 
the  extremities. 

Convulsions,  retracted  abdomen,  taches  cerebrales, 
contractions,  vomiting,  constipation,  and  the  variations 
in  respiration,  give  but  little  aid  in  forming  a  diagnosis 
between  the  two  forms  of  meningitis. 

It  is  very  important  to  distinguish  the  pseudo-hydro- 
cephalic  state  found  in  infants,  especially  during  diar- 
rhoea, dysentery,  and  other  exhausting  diseases.  This 
will  be  considered  under  Cerebral  Ansemia. 

It  will  sometimes  be  necessary  to  guard  against  be- 
ing deceived  by  the  possibility  of  reflex  irritations,  as 
teething,  ingestion  of  improper  food,  and  worms,  which 


TUBERCULAR  MENINGITIS.  67 

may  give  rise  to  convulsions  and  other  doubtful  symp- 
toms. 

Wilks  makes  tlie  following  statement :  "  If  you  meet 
with  an  obscure  case  of  recent  disease,  to  which  you  can 
only  apjDly  the  term  cerebral,  without  being  able  to  de- 
clare the  existence  of  any  special  lesion,  it  will  gener- 
ally turn  out  to  be  a  case  of  meningitis."  This  is  rather 
too  sweeping,  but  contains  considerable  truth. 

Peognosis. — Trousseau  mentions  two  cases  of  par- 
tial recovery  in  children,  one  with  paralysis.  The  child 
died  five  months  later  from  dysentery,  and  the  traces 
of  the  old  disease  were  found  at  the  autopsy.  In  adults 
it  is  very  doubtful  whether  recovery  is  possible,  and 
even  in  children  the  recoveries  are  so  few  that  practically 
there  is  no  reasonable  hope  of  a  favorable  termination. 

Teeatmei^t. — It  is  almost  hopeless  to  try  to  do  any- 
thing, but  we  can  refrain  from  being  too  meddlesome. 
The  active  treatment,  which  might  be  of  advantage  in 
simple  meningitis,  would  not  be  caUed  for  in  the  tuber- 
cular. The  cases  reported  as  recovering  were  treated, 
some  by  ergot  in  large  doses,  and  some  by  iodide  of  po- 
tassium in  large  doses  frequently  repeated. 

As  in  many  cases  a  diagnosis  is  doubtful,  and  as 
simple  meningitis  is  amenable  to  treatment,  it  will  often 
be  most  vdse,  excepting  depleting  measures,  to  treat  a 
case  of  suspected  tubercular  meningitis  as  if  it  were 
simple  meningitis. 


CHAPTER  IV. 

CHANGE   IN  BLOOD-SUPPLY. 

Jones,  C  H.  ,  Studies  on  Functional  Nervous  Disorders.  Lon- 
don, 1870,  p.  64,  86. — FOTHERGILL,  J.  M.,  Cerebral  Anaemia.  West 
Riding  Hospital  Reports,  vol.  iv,  1874,  p.  94.— Motta,  E.  A., 
Ueber  Hirnanamie  im  Algemeinen  und  insbesondere  iiber  Blutleere 
des  Gehirns  und  iiber  dessen  consecutive  Erweichung.  Deutsche 
KliniJc,  43, 1874.— Mitchell,  Weir,  Fat  and  Blood.  Philadelphia, 
1877.— Hewitt,  Graily,  Chronic  Starvation.  London  Lancet, 
Jan.  11,  1879,  p.  38. — Ball,  Benj.,  On  Certain  Cases  of  Function- 
al IschEemia  of  the  Brain.  Brit.  Med.  Jour.,  Oct.  30, 1880,  p.  693. 
— Jaccoud,  S.,  Traite  de  pathologie  interne,  1870,  t.  i,  p.  106. — 
MoxoN,  Walter,  Influence  of  the  circulation  upon  the  nervous 
system.    Brit.  Med.  Jour.,  1881,  I. 

CEREBRAL  ANJilMIA. 

Among  the  conditions  of  the  brain  most  difScult  for 
diagnosis  are  those  in  which  there  is  irregular  blood- 
supply.  There  are  several  reasons  for  this :  1.  An  over- 
worked brain  is  an  exhausted  brain ;  not  only  are  the 
proper  cerebral  nervous  elements  exhausted,  producing 
irregular  action,  but  the  vaso-motor  nervous  supply 
also  may  become  irregular  from  exhaustion  of  the  vaso- 
motor nerves.  2.  Another  cause  for  mistake  is  that  a 
badly  nourished  brain  is  irritable.  Hence  many  of  the 
symptoms  of  exhaustion  and  of  malnutrition  resemble 
those  found  in  congestion  or  stimulation  from  excess 
of  blood.  3.  Poor  blood,  that  which  is  not  suitable  for 
nourishment,  may  be  sent  in  large  amount  to  the  brain, 
and  there  will  still  be  practically  anaemia ;  the  nervous 
structures  may  have  lost  their  power  of  absorbing  the 


CEREBRAL  ANJEMIA.  69 

nutrient  materials  from  tlie  blood,  and  tlie  same  results 
follow. 

Under  anaemia  it  is  intended  to  comprise  all  those 
conditions  wherein  there  is  insuflScient  nutrition  of  the 
brain,  owing  to  defect  in  quantity  or  Quality  of  the 
blood. 

tEtiology. — When  there  is  general  anaemia  or  chlo- 
rosis, the  brain  usually  suffers  more  or  less  from  an  in- 
sufficient supply  of  healthy  blood.  Those  conditions, 
then,  are  causes  of  cerebral  anaemia  which  give  rise  to 
general  anaemia,  as  haemorrhages,  deficient  supply  of 
food,  bad  hygienic  surroundings,  exhausting  discharges, 
whatever  causes  a  poor  appetite  or  poor  digestion,  etc. 

A  hindrance  to  the  flow  of  blood  to  the  brain,  as 
pressure  on  the  arteries,  obstruction  of  their  caliber  by 
atheroma,  arteritis,  spasm,  embolism,  thrombosis,  may 
give  rise  to  a  deficiency  of  blood-supply  in  the  brain  as 
a  whole,  or  their  influence  may  be  local,  and  limited  to 
a  small  area.  The  same  result  follows  a  weakening  of 
the  heart's  action,  so  that  the  blood  is  not  sent  with 
sufficient  force  to  fill  the  cerebral  vessels. 

Deficient  oxidation,  absorption  of  poisons,  overheat- 
ing by  sun  or  artificial  heat,  hyperpyrexia  in  fevers, 
etc. ,  cause  a  defect  in  the  quality  of  the  blood,  render- 
ing it  unfit  for  the  healthy  nutrition  of  the  brain. 

Though  not  immediately  acting  upon  the  supply  of 
blood  nor  its  quality,  it  is  necessary  to  consider  the 
conditions  under  which  the  patient  has  lived.  Not 
only  do  anxiety  and  worry,  but  overwork,  mentally  or 
bodily,  and  loss  of  sleep,  by  exhausting  the  nervous 
system,  have  a  tendency  to  give  rise  to  an  irritability 
of  the  brain,  which  causes  it  to  show  the  effects  of  defi- 
cient blood-supply  more  quickly. 

There  are  very  few  cases  where  diminished  blood- 
supply  alone  is  the  cause  of  the  symptoms.  It  is  only 
in  the  acute  cases  following  sudden  haemorrhage  that 
this  is  true,  and  even  in  these  there  is  subsequently  de- 
ficient quality  of  blood.     Generally  changes  in  quality 


70  DISEASES  OF  TEE  BRAIN. 

concur  in  causing  the  symptoms.  Some  of  the  diseases 
in  which  the  symptoms  of  cerebral  anaemia  may  be 
found,  caused  by  changes  in  the  nutrition  of  the  blood, 
are  dysentery,  diarrhoea,  gastric  catarrh,  phthisis,  sup- 
purative diseases,  syphilis,  typhoid  and  other  fevers, 
and  malarial  poisoning. 

Pathological  Anatomy.  — There  is  simply  paleness 
of  both  white  and  gray  substance,  comparative  empti- 
ness of  the  blood-vessels,  and,  excepting  there  be  com- 
pression from  some  cause,  moisture  of  the  cut  surface. 
The  lymph-spaces  are  filled  with  serum  or  lymph  to  com- 
pensate for  the  diminished  fullness  of  the  blood-vessels. 
In  chronic  cases  there  is  undoubtedly  change  of  nutri- 
tion ;  but  our  means  of  examination  do  not  enable  us  to 
recognize  such  change. 

In  local  anaemia  from  obstruction  of  blood-vessels, 
changes  occur  which  will  be  more  properly  considered 
elsewhere. 

Symptoms. — The  symptoms  vary  according  as  the 
anaemia  is  acute  or  has  come  on  gradually.  If  the  pa- 
tient has  been  exhausted  by  previous  disease,  the  symp- 
toms will  be  less  violent  than  if  he  has  been  in  vigorous 
health.  Whether  the  brain  has  been  overworked  and 
excited  must  also  be  taken  into  consideration. 

When  a  rapid  haemorrhage  causes  cerebral  anaemia, 
the  attack  is  acute,  there  is  a  loss  of  mental  power,  ver- 
tigo, dimness  of  sight  and  of  hearing,  tinnitus,  sensa- 
tion becomes  blunted,  the  pupils  are  contracted,  then 
dilated,  the  skin  is  cool,  consciousness  is  lost,  and  con- 
vulsions occur.  Respiration  is  accelerated,  then  slow  ; 
pulse  small,  frequent,  and  of  diminished  tension.  This 
combination  of  symptoms  may  be  seen  not  only  in  se- 
vere haemorrhages,  as  in  surgical  and  obstetrical  prac- 
tice, but  less  completely  developed  where  a  patient 
greatly  exhausted  rises  from  the  bed  too  suddenly ; 
also  in  ordinary  fainting  from  whatever  cause. 

The  description  of  more  chronic  forms  of  cerebral 
anaemia  is  rendered  difficult  by  the  fact  that  very  few 


CEREBRAL  ANJEMIA.  71 

cases  are  uncomplicated.  Nervous  exhaustion,  from 
anxiety,  worry,  fatigue,  or  overwork  of  brain,  serves  to 
intensify  or  change  the  symptoms  ;  also  the  symptoms 
of  anaemia  and  hypersemia  of  the  brain  are  very  similar 
— so  similar  that  it  is  oftentimes  impossible  to  decide 
which  condition  is  present  without  regard  to  preceding 
circumstances.  Again,  an  irritable  brain,  anaemic  as  a 
whole,  may  be  locally  congested,  or  may  receive  tem- 
porarily an  increased  supply  of  blood,  though  a  supply 
below  that  appropriate  for  health,  and,  owing  to  its  ab- 
normal mitability,  be  excited  as  if  hypersemic. 

In  chronic  anaemia,  thought  is  an  effort,  sustained 
mental  exertion  is  impossible,  memory  is  uncertain,  the 
patient  is  drowsy ;  occasionally  after  rest  there  may  be 
Hashes  of  brilliancy,  but  they  are  brief.  If  effort  is 
absolutely  necessary,  the  patient  may  have  learned  that 
a  very  small  amount  of  wine  or  spirit  is  a  temporary  aid. 
Headache  is  one  of  the  most  annoying  symptoms,  and 
is  very  persistent,  and  may  incapacitate  for  the  ordi- 
nary duties  of  life.  After  lying  down  long  and  being 
quiet,  the  headache  may  be  relieved,  but  recurs  on  at- 
tempting to  go  about.  Perhaps,  in  part  owing  to  the 
headache,  in  part  owing  to  the  malnutrition  of  the 
nerve-centers,  there  is  likely  to  be  a  change  of  disposi- 
tion ;  irritability  of  temper,  fretf ulness,  and  peevish- 
ness are  seen.  Sometimes  there  is  dizziness  ;  more  fre-. 
quently  there  are  noises  in  the  head,  tinnitus  aurium, 
also  various  disturbances  of  vision,  muscae  volitantes, 
dimness,  even  amaurosis,  though  the  latter  is  rare. 
Respiration  may  not  be  much  changed,  but  there  may 
be  a  feeling  of  discomfort,  as  if  not  air  enough  were 
inspired,  and  so  there  is  sighing.  The  pulse  usually 
varies  only  slightly  from  the  normal,  unless  there  is 
present  some  disease  to  account  for  an  increased  rapid- 
ity, as  phthisis.  The  same  is  true  of  the  temperature  ; 
it  is  usually  about  normal  or  a  little  below,  but  may  be 
elevated  if  any  febrile  affection  exists.  General  weak- 
ness is  almost  always  seen,  but  rarely  complete  paraly- 


72  DISEASES  OF  THE  BRAIK 

sis.  Convulsions  are  not  seen  in  cases  of  chronic  ange- 
mia. 

When  the  anaemia  is  very  great,  there  may  occur 
delirium ;  if  the  anaemia  has  come  on  v^ith  moderate 
rapidity  in  a  rather  vigorous  person,  without  previous 
disease,  the  delirium  is  usually  active,  the  patient  may 
even  be  maniacal,  and  may  have  hallucinations,  hear- 
ing voices,  and  holding  conversations  vdth  imaginary 
persons  ;  he  may  not  recognize  his  friends,  or  may  de- 
sire to  escape.  This  feature  of  cerebral  anaemia  has  so 
much  the  appearance  of  excitement  from  hyperaemia 
that  many  refer  it  to  such  a  condition,  supposing  that 
there  is  local  congestion ;  but  the  active  delirium  is 
seen  only  v^hen  the  affection  has  been  developed  rather 
rapidly,  and  is  probably  owing  to  the  state  of  irritable 
weakness,  to  which  reference  has  already  been  made. 
When  the  anaemia  occurs  during  the  course  of  an  ex- 
hausting disease,  either  as  a  result  of  the  disease  or  of 
insufficient  feeding,  the  delirium  is  more  likely  to  have 
a  quiet  character.  Finally,  the  mental  powers  may  be 
entirely  lost. 

DiAaisrosis. — In  forming  a  diagnosis  of  this  affection 
it  is  necessary  to  take  into  consideration  the  previous 
circumstances  of  the  patient.  The  diagnosis  from  hy- 
peraemia  may  be  very  difficult,  and,  as  t^e  treatment 
would  be  quite  different,  it  is  important  to  be  as  nearly 
correct  as  possible.  If  there  is  a  history  of  long-con- 
tinued privation,  with  worry  and  anxiety,  or  of  hard 
work,  physical  or  mental,  and  loss  of  appetite,  or  ex- 
hausting discharges,  it  is  probable  that  the  condition 
is  anaemic,  although  there  may  be  much  excitement. 
It  is  sometimes  more  difficult  to  decide,  where  there  is 
active  delirium,  whether  it  is  insanity  or  anaemia.  Here 
also  the  previous  history  will  be  of  assistance  ;  but,  as 
anaemia  may  lead  to  change  of  structure  in  the  nerve- 
cells,  it  may  pass  over  into  insanity,  and  without  mania 
it  may  pass  into  melancholia.  In  insanity  induced  by 
cerebral  anaemia  there  is  not  a  long-continued  period  of 


CEREBRAL  ANAEMIA.  73 

excitement ;  the  condition  is  rather  one  of  depression, 
with  occasional  attacks  of  irritability. 

To  recognize  that  delirium  in  febrile  diseases  is  ow- 
ing to  cerebral  anaemia  is  all-important.  Especially  in 
children  with  gastro-intestinal  affections  the  symptoms 
resemble  those  of  serious  organic  brain  disease ;  the 
previous  history  must  not  be  overlooked  ;  it  would  be 
disastrous  to  treat  a  child  with  anaemia  for  meningitis. 
During  typhoid  fever  in  adults  there  may  be  a  similar 
mistake.  It  would  seem  that  care  in  watching  the 
patient — not  only  the  fever,  but  also  the  feeding  of  the 
patient — might  prevent  such  an  error.  Excessively  high 
temperatures  may  give  rise  to  symptoms  similar  to  those 
of  anaemia ;  a  careful  use  of  the  thermometer  will  guard 
against  this  mistake. 

Peogjstosis. — If  there  is  no  serious  complication,  as 
cardiac  or  Bright's  disease,  the  prognosis  is  favorable, 
provided  sources  of  exhaustion  can  be  removed.  The 
prognosis  in  the  case  of  other  diseases  may  be  favor- 
able for  the  anaemia,  though  unfavorable  for  the  pri- 
mary disease. 

Treatmeis^t. — If  the  case  is  one  of  acute  anaemia, 
or  of  extreme  weakness  after  protracted  disease  or  ex- 
hausting discharges,  it  will  be  very  important  to  keep 
the  head  low ;  perhaps  the  foot  of  the  bed  should  be 
raised ;  the  body  should  be  kept  warm,  by  artificial 
means  if  necessary  ;  stimulants  may  be  necessary  ;  food 
in  a  form  easily  digested,  in  small  amounts,  frequently 
repeated. 

The  chronic  form  needs  methodical  rest  and  feed- 
ing. As  many  of  the  symptoms  are  due  to  exhaustion 
of  the  nervous  system,  the  effort  should  be  made  to 
withdraw  the  patient  from  all  such  influences  as  tend 
to  exhaust  him.  In  many  cases  the  course  of  treat- 
ment recommended  by  Weir  Mitchell  in  "Fat  and 
Blood"  will  give  excellent  results.  In  every  case  the 
best  tonic  is  food.  The  food  must  be  easily  assimilated, 
not  in  too  great  quantities,  and  should  be  taken  at  short 


74:  DISEASES  OF  THE  BEAIK 

intervals.  Milk  is  one  of  tlie  best  to  begin  with. ;  not 
only  is  it  easily  digested  and  contains  all  the  constitu- 
ents of  the  body,  but  is  largely  composed  of  water. 
Fothergill's  remarks  about  water  in  ansemia  are  deserv- 
ing of  attention.*  Among  drugs,  arsenic,  iron,  and 
quinine  are  valuable. 

Where  there  is  restlessness,  sleeplessness,  delirium, 
it  may  be  necessary  to  give  chloral  and  bromide  of  po- 
tassium, or  paraldehyde.  Small  doses  of  these  are 
worse  than  useless ;  even  if  frequently  repeated,  they 
are  not  efficacious ;  less  than  twenty  grains  of  each 
is  not  sure  of  giving  rest ;  in  many  cases  it  may  be 
necessary  to  give  thirty  or  even  forty  grains  at  one 
dose.  Yet  chloral  should  be  given  with  caution,  and 
not  administered  every  time  a  patient  does  not  sleep  ; 
it  is  often  given  injudiciously.  Spirit  will  sometimes 
aid  sleep.  Opium  is  a  valuable  agent,  and  may  often 
be  given  to  advantage  in  small  doses — a  tenth  or  twelfth 
of  a  grain — the  object  being  rather  to  obtain  its  stimu- 
lating effect.  Sleep  may  sometimes  be  produced  by  a 
grain  or  two  or  quinine  at  bedtime,  or  by  a  dose  of 
phosphoric  acid,  or  by  a  light  lunch  just  before  retir- 
ing. A  cup  of  beef-tea  during  the  night  may  overcome 
the  habit  of  lying  awake. 

CEREBRAL  HYPERiEMIA. 

When  the  arteries  are  distended,  or  there  is  an  in- 
creased flow  of  blood  through  them,  there  is  active  hy- 
persemia  ;  when  the  veins  are  over-distended,  it  is  pas- 
sive. The  latter  condition  may,  in  reality,  be  one  of 
anaemia,  so  far  as  concerns  the  state  of  the  circulation 
in  the  brain. 

Some  authors  deny  the  existence  of  cerebral  conges- 
tion. 

Causes. — Probably  a  predisposition  to  cerebral  hy- 
persemia  is  constitutional  with  some  persons,  just  as 

*  "  Handbook  of  Treatment,"  pp.  51,  52. 


CEREBRAL  HYPEREMIA.  75 

some  blush  more  easily  than  others  ;  the  predisposition 
may  be  acquired.  Whatever  has  a  tendency  to  cause  a 
fullness  of  the  cerebral  arteries,  and  keep  the  blood 
flowing  rapidly  through  the  brain,  may  give  rise  finally 
to  a  predisposition  to  cerebral  hypersemia.  Excessive 
and  often-repeated  emotional  disturbances,  excessive  and 
protracted  brain- work,  are  among  these  agents.  But 
it  must  be  kept  in  mind  that  these  also  produce  exhaus- 
tion, and  so  irritability,  which  may  lead  the  brain  to 
respond  unhealthily  to  the  normal  amount  of  blood,  or 
to  be  excessively  excited  by  less  than  the  normal 
amount. 

Among  other  influences  may  be  mentioned  a  low 
temperature  ;  thus,  most  cases  are  said  to  occur  in  win- 
ter. A  very  high  temperature  is  also  said  to  cause  con- 
gestion, and  especially  if  the  sun  shines  directly  upon 
the  head ;  but  the  symptoms  following  such  exposure 
are  rather  due  to  elevation  of  temperature  and  change 
in  the  quality  of  the  blood. 

Increased  activity  of  the  heart  is  also  said  to  be  a 
cause  of  cerebral  congestion ;  hence  violent  exertions 
may  give  rise  to  it. 

Certain  drugs  may  cause  cerebral  hypersemia,  as 
nitrite  of  amyl.  Opium  and  belladonna  have  been 
thought  to  do  so  ;  but  this  is  not  certain.  Alcohol  may 
act  as  a  cause,  but  only  acutely ;  chronic  alcoholism 
acts  rather  by  producing  changes  in  the  quality  of  the 
blood,  and  so  changes  in  the  nerve-structures. 

Malarial  poison  may  excite  congestion  of  the  brain  ; 
indeed,  probably  every  attack  of  chills  and  fever  is  at- 
tended with  cerebral  hypersemia,  and  this  may  be  one 
cause  of  danger  in  severe  malarial  diseases. 

Passive  congestion  may  be  caused  by  any  interfer- 
ence with  the  return  of  the  blood  from  the  brain. 

Pathology. — In  acute  cases  very  little  change  may 
be  expected  ;  much  or  most  of  the  blood  drains  off  post- 
mortem. Yet  even  then,  and  with  rather  more  fre- 
quency in  cases  of  longer  standing,  the  smaller  vessels 


76  DISEASES  OF  TEE  BRAIN. 

in  tlie  cerebral  substance  show  with  unusual  distinct- 
ness upon  section.  The  surface  of  the  section  is  thickly 
sprinkled  with  bloody  points,  the  gray  substance  is 
darker,  and  the  white  substance  may  have  a  decided 
pinkish  color,  from  the  fullness  of  the  minutest  vessels. 

In  chronic  cases  the  constant  dilatation  of  the  ves- 
sels may  lead  to  changes  around  them  ;  the  perivascu- 
lar sheaths  may  contain  granules  of  blood  pigment. 
There  are  seen,  also,  cavities  in  the  brain  containing  the 
transverse  section  of  a  vessel.  These  are  thought  by 
some  to  be  caused  by  dilated  perivascular  sheaths,  by 
others  to  be  dependent  u]Don  dilatation  of  the  vessels. 
The  latter  may  act  as  one  agent  in  their  production, 
another  may  be  shrinking  of  the  cerebral  substance,  a 
slight  atrophy  which  causes  a  dilatation  of  the  peri- 
vascular sheaths. 

Constant  and  repeated  hypersemia  must  interfere 
with  the  nutrition  of  the  nervous  structures ;  the  high 
blood-pressure  is  unfavorable  for  the  interchange  of 
elements.  The  changes  thus  resulting  occur  slowly,  but 
finally  may  be  very  serious  and  may  lead  to  insanity. 
These  changes  will  also  explain  why  it  often  requires 
so  long  a  time  for  recovery  from  symptoms  which  seem 
insignificant.  In  this  connection  it  must  be  remem- 
bered that  not  only  do  the  proper  structures  of  the 
brain  suffer,  but  also  the  walls  of  the  blood-vessels  and 
their  vaso- motor  nerves  undergo  changes — at  least 
functional  changes,  and  probably  slight  organic  changes. 

Symptoms. — Many  of  the  symptoms  of  cerebral  hy- 
persemia are  the  same  as  are  found  in  cerebral  anaemia, 
and  many  which  are  usually  ascribed  to  hypersemia  are 
quite  as  dependent  upon  exhaustion  from  overwork, 
anxiety,  etc.  It  is  impossible  to  entirely  separate  the 
two  classes  of  symptoms  in  giving  an  account  of  the 
affection. 

If  not  severe,  there  may  be  a  sense  of  heaviness,  or 
pain  in  the  head,  with  tinnitus  (though  this  is  more 
common  in  anaemia),  dizziness,  sleeplessness,  more  or 


CEREBRAL  HYPEREMIA.  77 

less  agitation,  perhaps  at  times  a  tingling  sensation  in 
the  fingers  or  feet,  as  if  they  were  "asleep."  These 
symptoms  at  first  recur  only  occasionally,  but  may  be- 
come more  permanent. 

There  may  be  more  serious  symptoms  :  the  tempera- 
ment may  be  changed  and  the  patient  be  fretful  and 
irritable,  the  mental  power  diminished,  and  there  may 
be  absolute  inability  to  apply  the  mind  in  certain  direc- 
tions. When  an  intense  application  of  the  mind  to  one 
class  of  questions  has  brought  on  the  affection,  there  is 
inability  to  apply  the  mind  in  that  direction.  A  teacher 
can  not  teach  ;  the  effort  to  do  so  may  cause  such  con- 
fusion that  he  will  have  no  command  over  his  speech  ; 
or  a  lawyer  may  be  unable  to  try  a  case  before  a  jury, 
the  attempt  to  do  so  being  preceded  by  sleepless  nights, 
and  accompanied  by  such  distress,  or  even  semi-delirium, 
as  to  make  it  impossible.  It  would  seem  as  though  in 
these  cases  there  is  a  local  irritability  of  the  nerve-cen- 
ters relating  to  such  pursuits,  which,  when  an  attempt 
is  made  to  use  these  centers,  gives  rise  to  an  increased 
flow  of  blood,  not  only  to  them,  but  to  other  parts  of  the 
brain  also.  It  is  interesting  to  note  that  the  use  of  other 
centers  has  not  this  effect :  thus,  the  lawyer  who  can  not 
try  a  case  in  court  may  be  able  to  attend  to  other  busi- 
ness (though  it  is  not  by  any  means  safe  to  allow  ii) ; 
the  merchant  may  not  be  able  to  keep  the  run  of  his 
goods,  but  he  can  attend  to  his  garden  and  care  for  his 
country  residence  without  distress. 

Memory  is  affected:  there  is  confusion,  dullness, 
wrong  words  are  used  in  talking  ;  there  may  be  deliri- 
um, or  the  excitement  may  run  into  mania.  At  times 
there  may  be  weakness  of  the  limbs,  twitching  of  mus- 
cles, especially  of  the  face  ;  paralyses  almost  never  oc- 
cur ;  convulsions  belong  rather  to  ansemia  or  epilepsy ; 
and  also  disturbances  of  sight  and  hearing  are  more  fre- 
quent in  anaemia ;  vomiting  is  rare.  Respiration  is  little 
affected  ;  the  pulse  is  usually  full  and  resistant,  perhaps 
rapid,  possibly  moderate.     The  face  is  usually  flushed 


Y8  DISEASES  OF  THE  BRAIN. 

or  ruddy,  is  rarely  pale,  and  tlie  conjimctivse  may  be 
injected. 

Many  authors  describe  a  form  of  this  affection  at- 
tended with  convulsions,  which,  however.  Trousseau 
refers  to  epilepsy,  and  this  explanation  is  now  gener- 
ally accepted. 

There  is  a  condition  which  I  have  met  a  few  times 
which  seems  to  be  dependent  on  congestion  rather  than 
anaemia.  I  have  only  seen  it  in  women  run  down  ner- 
vously ;  so  nervous  exhaustion  is  one  element  in  causing 
it.  The  patient,  after  some  emotion  or  shock,  only 
slightly  more  severe  than  usual,  or  after  some  exertion, 
as  ascending  stairs,  feels  weak,  is  unable  to  stand  or  sit, 
has  distress  in  the  head,  then  loses  all  power  of  motion, 
and  speech ;  lies  as  if  in  a  faint,  but  the  face  is  flushed  ; 
the  heart  beats  vigorously,  perhaps  not  more  so  than 
normal ;  respiration  is  little  if  at  all  affected.  If  the 
attack  is  not  severe,  the  patient  may  lie  utterly  help- 
less, unable  even  to  move  an  eyelid,  yet  know  all  that 
is  said  and  done.  In  severer  cases,  consciousness  is  lost. 
I  have  known  such  an  attack  to  last  two  or  three  hours. 
There  is  no  spasmodic  action.  Recovery  is  gradual, 
then  respiration  may  be  sighing  ;  subsequently  there  is 
-great  distress  in  the  head  and  confusion  of  thought  for 
several  hours. 

These  attacks  may  occur  during  the  night,  either  in 
consequence  of  a  dream  or  from  the  previous  day's  ex- 
haustion and  the  recumbent  position.  One  gentleman 
told  me  that,  after  learning  that  his  wife  had  these,  the 
peculiar  respiration,  in  her  case  noisy,  aroused  him. 
These  attacks  differ  from  epilepsy  in  that  a  definite 
cause  can  be  so  frequently  traced  that  it  is  reasonable 
to  think  such  a  cause  always  exists ;  they  recur  as  ir- 
regularly as  the  causes  which  give  rise  to  them. 

DiAGisrosis. — It  is  not  always  easy  to  distinguish 
congestion  from  anaemia  or  from  simple  nervous  ex- 
haustion. Sometimes  it  is  necessary  to  suspend  judg- 
ment for  a  while  to  watch  the  course  of  the  symptoms. 


CEREBRAL  HYPEREMIA.  79 

A  superficial  examination  of  the  patient  will  be  as  likely 
to  lead  to  an  error  in  diagnosis  as  to  give  correct  re- 
sults. 

Some  physicians  recognize  hypersemia  in  almost 
every  obscure  morbid  functional  state  of  the  brain ; 
others  disbelieve  in  it  entirely. 

The  previous  history  of  the  patient  will  assist  mate- 
rially in  diagnosis.  Has  the  patient  been  well  fed,  or 
poorly  ?  been  happily  situated,  or  miserably  ?  had  pros- 
perity or  poverty  ?  have  there  been  exhausting  drains 
upon  the  system,  frequent  small  haemorrhages,  or  se- 
verer haemorrhages  ?  Is  the  patient  full-blooded  or  gen- 
erally ansemic?  Is  the  face  ruddy,  flushed,  or  pale? 
Did  the  attack  come  on  as  the  result  of  excitement,  or 
during  the  strain  of  some  intense  mental  effort,  or  dur- 
ing a  violent  physical  exertion  ?  All  these  inquiries 
will  assist  in  forming  a  correct  diagnosis  when  the 
symptoms  are  uncertain. 

A  diagnosis  depending  upon  the  symptoms  may  be 
made  in  many  cases  with  some  degree  of  probability. 
In  anaemia  the  symptoms  are  those  of  excitement  only 
in  rare  cases,  and  then  the  excitement  is  not  of  long 
duration  ;  as  a  rule,  in  the  more  chronic  cases  there  is 
depression.  In  hypersemia,  excitement  and  exaltation 
predominate,  and  there  is  apparent  depression  only 
when  the  brain  is  overpowered  by  the  severity  of  the 
attack,  or  the  congestion  is  passive.  The  headache  is 
more  acute  in  anaemia  ;  more  of  a  feeling  of  painful  full- 
ness in  hypersemia.  The  pulse  is  fuller  and  more 
bounding  in  hyperaemia.  These  peculiarities,  with  at- 
tention to  the  whole  group  of  symptoms  as  described 
above  under  both  these  affections,  will  in  most  cases 
lead  to  a  correct  diagnosis.  It  would  be  easy  to  pick 
out  typical  cases  of  both  these  conditions  from  actual 
practice  and  describe  them,  but  such  cases  are  not 
easily  mistaken,  and,  unfortunately,  form  only  a  small 
proportion  of  the  cases  we  see.  As  in  many  other 
diseases,  a  careful  examination  and  consideration  of 


80  DISEASES  OF  TEE  BRAIK 

all  the  circumstances  are  necessary  to  a  correct  diag- 
nosis. 

Other  affections  which  must  be  separated  from  cere- 
bral congestion  are  cerebral  haemorrhage,  cerebral  em- 
bolism, and  thrombosis.  These  will  be  better  consid- 
ered under  those  affections.  Vertigo  from  disease  of 
the  ear  and  from  derangement  of  the  digestive  organs 
also  needs  to  be  distinguished. 

The  most  important  affection,  next  to  ansemia,  to 
correctly  recognize  is  epilepsy.  Some  forms  of  epi- 
lepsy are  so  obscure,  especially  in  the  commencement 
of  that  affection,  that  it  is  no  uncommon  circumstance 
to  have  it  overlooked,  and  the  patient,  his  friends,  and 
perhaps  the  physician,  consider  the  attack  is  a  mere 
passing  rush  of  blood  to  the  head.  This  will  be  more 
intelligently  considered  under  epilepsy. 

A  reasonable  care  in  the  examination  of  the  urine 
will  suffice  to  distinguish  Bright's  disease,  which  may 
give  rise  to  symptoms  closely  resembling  those  caused 
by  disturbance  of  the  cerebral  circulation.  The  urine 
should  be  examined  more  than  once  if  the  diagnosis  is 
doubtful. 

Peogi^osis. — The  danger  from  an  attack  of  cerebral 
congestion  depends  upon  the  severity  of  the  attack  and 
its  suddenness.  The  brain  may  be  completely  over- 
powered by  the  sudden  influx  of  blood,  consciousness 
may  be  lost,  and,  if  the  medulla  is  also  affected,  life 
may  be  extinguished  at  once  or  very  soon.  Walter 
Moxon,  however,  finds  no  satisfactory  post-mortem  evi- 
dence that  acute  congestion  is  ever  a  cause  of  death. 

But  generally  the  patients  do  not  die  at  once,  and 
in  chronic  cases  there  seems  to  be  no  immediate  danger 
to  life.  Recovery,  however,  is  tedious.  Almost  al- 
ways there  have  been  various  circumstances  in  the  pa- 
tient's history  acting  as  predisposing  causes,  and  this 
is  one  reason  for  the  slow  recovery.  Where  there  is  no 
complication,  a  recovery  may  be  expected  in  time,  pro- 
vided the  patient  will  submit  to  proper  treatment. 


CEREBRAL   HTPERyEMIA.  81 

Among  other  complications,  the  most  unfavorable  is 
organic  change  in  the  nervous  elements  of  the  brain. 
This  may  give  rise  to  insanity. 

Treatment. — Congestion  of  the  brain  may  be  ac- 
companied with  so  severe  symptoms,  with  such  imme- 
diate danger  to  life,  with  unnatural  fullness  of  the 
arteries,  with  such  strong  action  of  the  heart,  that  gen- 
eral bleeding  is  indicated.  These  cases  are,  however, 
rare,  and  such  bleeding  would  not  be  advisable  in  any 
except  a  robust  and  plethoric  patient.  Xocal  bleeding 
by  cups  or  leeches  would  be  beneficial  in  a  larger  num- 
ber of  cases.  In  the  severer  forms,  when  it  is  not  de- 
sirable to  withdraw  blood,  means  may  be  taken  to  in- 
crease the  flow  of  blood  to  distant  parts  of  the  body,  as 
by  hot  foot-baths  or  mustard  foot-baths  ;  or  to  diminish 
the  amount  of  blood  by  acting  on  the  bowels,  saline 
cathartics,  croton  -  oil,  etc.  ;  or  by  promoting  copious 
sweating  by  hot-air  baths,  steam  baths,  hot -water 
baths,  keeping  ice  on  the  head.  Jaborandi  acts  espe- 
cially on  the  skin ;  but,  as  it  frequently  gives  rise  to  vio- 
lent vomiting,  it  would  be  hardly  safe,  lest  the  straining 
in  vomiting  should  increase  the  congestion. 

Cold  applications  to  the  head — ice,  a  rubber  tube 
coiled  up,  with  cold  water  running  through  it,  evapo- 
rating lotions — ^may  give  relief ;  but  to  be  of  much  bene- 
fit, the  application  must  be  continuous. 

When  there  is  violent  delirium,  mania,  as  one  of 
the  most  marked  symptoms,  it  will  be  frequently  found 
that  there  have  been  circumstances  tending  to  render 
the  brain  excitable.  The  measures  already  mentioned 
may  be  employed  :  sometimes  a  wet  cup  to  the  back  of 
the  neck  taking  a  few  ounces  of  blood  aids  in  giving 
relief  ;  sometimes  a  dry  cup  gives  equal  relief.  Bro- 
mide of  potassium  and  chloral,  in  doses  suflBcient  to 
produce  sleep,  are  especially  indicated  ;  from  thirty  to 
sixty  grains  of  each.  Small  doses  of  chloral  repeated 
hourly  have  no  effect,  but  rather  aggravate  the  symp- 
toms, and  the  combination  of  the  two  drugs  is  more 

6 


82  DISEASES  OB   TEE  BRAIN. 

efficacious  than  either  alone.  Hyoscyamus  will  often 
procure  sleep  and  quiet  if  given  in  large  doses.  In  cases 
of  mania  from  cerebral  hypersemia,  opium  should  not 
be  given,  but  during  delirium  from  anaemia  it  may  be 
beneficial. 

Where  the  hypereemia  is  chronic  and  has  been  pro- 
duced by  excessive  mental  application,  or  by  constant 
emotional  excitement,  the  first  indication  is  to  remove 
the  cause.  The  patient  should  drop  his  studies,  his 
business,  whatever  has  intensely  occupied  him,  and 
withdraw  from  all  associations  which  give  rise  to  emo- 
tional disturbance.  A  quiet,  regular,  systematic  life, 
with  easily  digested,  mild  food,  is  the  most  favorable. 
Bromide  of  potassium,  without  chloral,  fifteen  or  twenty 
grains  three  times  a  day.  Bromide  of  sodium,  lithium, 
calcium,  or  ammonium,  have  been  used  instead,  and 
are  more  agreeable  to  some  patients.  Ergot,  either  as 
fluid  extract,  half  a  drachm  to  a  drachm,  or  ergotin, 
three  to  five  grains,  three  times  a  day.  Ice  to  the  back 
of  the  neck  will  sometimes  relieve  the  discomfort  in 
the  head  better  than  when  applied  to  the  head  directly. 

Most  cases  of  chronic  cerebral  hypersemia  are  also 
complicated  with  nervous  exhaustion,  and  it  may  be 
desirable  to  give  tonics  to  counteract  the  exhaustion. 
The  vaso-motor  nervous  system  is  at  fault,  and  requires 
not  only  a  temporary  stimulant  to  cause  the  arteries  to 
contract,  but  it  needs  also  to  be  permanently  strength- 
ened. A  systematic  course  of  hydrotherapy  may  be  of 
value  in  this  direction  ;  also  the  ordinary  tonics. 

The  chief  object  of  these  remedies  is  to  restore  the 
normal  action  of  the  arteries  and  the  vaso-motoj*  nerves. 
To  do  this,  iron,  strychnia,  arsenic,  quinine,  zinc,  nu- 
tritious but  unstimulating  food,  are  the  most  valuable 
agents.  Spirituous  liquors  are  to  be  avoided  ;  tea  and 
coffee  taken  only  in  moderation,  if  at  all ;  tobacco 
should  be  forbidden.  It  is  scarcely  necessary  to  men- 
tion that  the  digestive  and  other  functions  should  be 
kept  in  a  normal  condition. 


CEREBRAL  HYPEREMIA.  83 

Those  wlio  have  had  attacks,  or  who  seem  liable  to 
attacks  of  cerebral  congestion,  should  avoid  public 
gatherings  where  the  air  is  likely  to  become  impure 
and  heated,  and  where  there  is  more  or  less  excitement, 
as  theatres,  concerts,  balls,  etc.  They  should  be  quiet 
in  all  their  movements,  avoiding  exertions  which  would 
cause  an  increase  of  blood  -  pressure  in  the  brain,  as 
running,  lifting  weights,  straining  at  stool,  and  venereal 
indulgence.  They  should  sleep  in  cool,  well-ventilated 
rooms ;  better  on  a  hair  mattress,  with  head  elevated. 
They  should  take  exercise  in  the  open  air,  but  avoid 
being  chilled  in  cold  weather.  All  intellectual  efforts 
which  produce  the  least  discomfort  in  the  head  should 
be  avoided.  As  one  can  not  stay  at  home  surrounded 
by  familiar  objects  without  the  mind  running  more  or 
less  in  its  old  ruts,  and  being  recalled  by  old  associa- 
tions into  old  trains  of  thought,  it  is  especially  impor- 
tant to  break  up  all  such  associations  in  cases  of  chronic 
hypersemia,  and,  where  the  patient's  health  permits, 
traveling  or  a  sojourn  away  from  home  is  very  desira- 
ble. Often  it  is  the  method  whereby  quickest  relief 
can  be  obtained. 


CHAPTER  Y. 

H^MOEEHAGE. 

Charcot  et  Bouchard,  Nouvelles  recherches  sur  la  patho- 
genie  de  I'hemorrhagie  cerebrale.  Arch,  de  physiol.,  1868. — Du- 
RAND,  C,  Des  anevrysmes  du  cerveau  consideres  principalement 
dans  leurs  rapports  avec  I'heraorrhage  cerebrale.  Paris,  1868. — 
BouRNEViLLE,  Etudes  cliniques  et  thermometriques  sur  les  mala- 
dies du  systeme  nerveux.  Paris,  1872. — Broadbent,  William  H., 
On  Ingravescent  Apoplexy,  a  Contribution  to  the  Localization  of 
Cerebral  Lesions.  Med.  Chir.  Trans. ,  59, 1876.— Gowers,  William 
R.,  On  "Athetosis"  and  Post-hemiplegic  Disorders  of  Movement. 
Med.  Chir.  Trans.,  59,  1876.— Lidell,  J.  A.,  A  Treatise  on  Apo- 
plexy, Cerebral  Hsemorrhage,  Cerebral  Embolism,  etc.  New  York, 
1873. — Thomson,  W.  H.,  Prophylaxis  of  Hemiplegia.  New  York 
Med.  Record,  1878. — Sanders,  Edward,  A  Study  of  Primary,  Im- 
mediate, or  Direct  Hasmorrhage  into  the  Ventricles  of  the  Brain. 
Am.  Jour.  Med.  Sci.,  July  and  October,  1881. — Drozda,  Jos.  V., 
Statistische  Studien  iiber  die  Hemorrhagia  cerebri.  Wien.  med. 
Presse,  March  7,  1880. 

MENINGEAL  niEMORRHAGE. 

When  a  vessel  of  tlie  dura  mater  ruptures,  the  blood 
may  escape  either  between  the  dura  and  the  skull,  or 
into  the  dura  itself,  between  the  layers  of  its  fibers,  or 
between  it  and  layers  of  false  membrane.  The  former 
is  more  frequently  the  result  of  an  injury ;  the  latter  is 
found  in  pachymeningitis  hsemorrhagica.  The  blood 
may  also  escape  into  the  arachnoid  space.  This  is  not 
common,  and,  when  it  occurs,  it  can  not  be  distinguished 
from  haemorrhage  following  the  rupture  of  one  of  the 
vessels  of  the  pia  mater. 


MENINGEAL  EJEMOREEAQE.  85 

JEtiology. — The  causes  of  haemorrhage  are  blows 
and  falls,  bursting  of  aneurisms,  other  disease  of  blood- 
vessels, or  thrombosis  of  sinuses.  Rupture  of  aneurisms 
is  the  more  common  cause ;  these  may  be  either  mili- 
ary or  of  considerable  size.  The  effused  blood  may  be 
but  little  in  amount,  or  may  cover  a  large  extent,  even 
dipping  down  into  the  sulci  and  fissures,  and  extending 
to  both  sides  or  penetrating  into  the  ventricles. 

Pathological  Anatomy. — The  blood  is  usually 
poured  out  in  such  quantity  that  death  follows  before 
any  change  can  take  place  in  the  clot ;  occasionally 
death  is  delayed  long  enough  to  show  that  absorption 
has  commenced,  and  in  a  very  few  instances  the  blood 
has  been  in  such  small  quantity  that  it  has  been  ab- 
sorbed, and,  subsequently,  the  remains  found  in  pig- 
mented spots  on  the  membranes.  In  these  cases  there 
is  a  reasonable  doubt  whether  the  disease  is  not  pachy- 
meningitis rather  than  meningeal  haemorrhage. 

Symptoms. — The  symptoms  will  vary  according  to 
the  locality  and  extent  of  the  haemorrhage.  If  there 
has  been  previous  disease  of  blood-vessels,  especially 
an  aneurism  of  considerable  size,  there  will  have  been 
corresponding  symptoms  preceding  the  attack.  Many 
times  these  will  be  merely  headache,  lassitude,  heavi- 
ness, vertigo. 

If  the  blood  escapes  suddenly  in  one  gush,  there 
will  be  a  sudden  and  immediate  loss  of  consciousness, 
and  paralysis  with  slow  pulse  and  stertorous  respira- 
tion, and  the  patient  may  soon  die.  If  the  blood  es- 
caxDes  less  rapidly,  the  loss  of  power  will  come  on  gradu- 
ally, and  the  patient  may  be  able  to  walk  across  the 
room,  or  even  farther,  and  call  for  assistance  before 
sinking  to  the  floor  and  losing  consciousness. 

According  to  the  locality  of  the  haemorrhage,  to  the 
irritation  excited  by  it,  and  perhaps  other  illy  defined 
circumstances,  there  may  be  convulsions  attending  the 
attack.  These  may  affect  one  or  more  limbs,  may  be 
universal,  or  may  only  affect  certain  cranial  nerves. 


86  DISEASES  OF  THE  BRAIN. 

Occasionally  the  patient  recovers  from  the  first  at- 
tack of  unconsciousness,  and  seems  to  be  gaining  until 
another,  and,  perhaps,  several  successive  attacks  ter- 
minate fatally. 

The  symptoms  are  the  result  of  a  combination  of 
local  irritation,  pressure,  and  anaemia  of  the  brain.  If 
the  vessel  is  in  the  pia  mater,  the  blood  may  be  poured 
out  with  such  violence  and  in  such  a  direction  as  to  tear 
up  a  portion  of  the  cortex  immediately  adjacent. 

DiAGisrosis.  —  The  peculiarities  wherein  meningeal 
haemorrhage  differs  from  intra- cerebral  haemorrhage 
are,  the  more  frequent  occurrence  of  convulsions  and 
contraction  in  about  a  quarter  of  the  cases  ;  the  paraly- 
sis is  less  likely  to  be  local,  all  the  limbs  suffer  alike, 
and  there  is  gradually  diminishing  power  until  total 
paralysis  is  reached,  though  sometimes  there  is  hemi- 
plegia. The  temperature  follows  very  much  the  same 
course  as  in  intra-cerebral  haemorrhage. 

PKOGisrosis. — Excepting  in  very  rare  instances,  death 
is  the  invariable  result. 

Treatment. — The  treatment  is  the  same  as  for  in- 
tra-cerebral haemorrhage. 

CEREBRAL   HEMORRHAGE. 

Cerebral  haemorrhage  and  apoplexy  are  not  syn- 
onymous terms.  The  latter  is  applied  to  all  attacks 
wherein  there  is  sudden  loss  of  consciousness  without 
convulsions,  coma  continuing  for  a  longer  or  shorter 
time,  ending  in  death,  or  partial  or  entire  recovery. 
This  may  be  the  result  of  other  causes  than  haemor- 
rhage, as  congestion,  or  plugging  of  an  artery  by  an 
embolus. 

Etiology. — The  amount  of  blood  poured  out  de- 
pends upon  the  size  of  the  blood-vessel ;  also  upon  its 
situation.  The  white  substance  is  much  more  easily 
torn  up  than  the  gray  substance,  and,  when  the  blood 
bursts  into  one  of  the  ventricles,  there  is  much  less 


cer:ebral  emmorreage.  sT 

resistance  to  the  bleeding  than  when  it  is  confined  by 
the  cerebral  substance.  The  form  of  the  clot  and  of  the 
cavity  containing  it  depends  upon  the  direction  of  the 
nerve-fibers  among  which  the  blood  is  poured  out. 

The  size  of  the  clot  may  vary  from  that  of  a  pin's 
head  or  of  a  pea  to  a  clot  occupying  nearly  the  whole 
of  a  hemisphere.  The  largest  clots  are  those  where  the 
haemorrhage  begins  in  the  corpus  striatum  or  the  optic 
thalamus,  and  extends  into  the  white  substance  of  the 
centrum  ovale.  The  relations  which  the  size  of  the  clots 
and  the  frequency  of  haemorrhage  bear  to  the  cerebral 
circulation  are  considered  by  Duret.  The  anterior  part 
of  the  caudate  nucleus  is  supplied  by  nutrient  branches 
arising  from  the  anterior  cerebral  and  anterior  commu- 
nicating arteries.  These  are  all  small ;  haemorrhages 
here  are  rare,  and  are  usually  small.  The  lenticular 
nucleus,  and  the  anterior  portion  of  the  optic  thala- 
mus, are  supplied  by  arteries  from  the  middle  cere- 
bral, which  is  a  large  artery  and  nearly  in  line  with  the 
carotid ;  the  nutrient  branches  are  comparatively  large, 
and  haemorrhages  more  frequently  occur  from  these  and 
are  more  likely  to  be  copious.  There  are  no  large 
arteries  running  through  the  centrum  ovale ;  hence 
haemorrhages  here  are  rare  and  of  small  extent.  The 
posterior  lobe  is  supplied  with  larger  vessels  from  the 
posterior  cerebral  artery  ;  hence  haemorrhages  of  consid- 
erable size  may  be  found  there.  These  are  some  of  the 
more  important  and  interesting  conclusions  at  which 
Duret  arrives. 

To  Charcot  and  Bouchard  belongs  the  credit  of  re- 
ferring cerebral  haemorrhage  to  a  periarteritis  of  the 
smaller  arterioles,  the  external  coats  being  first  affected. 
There  is  an  increase  of  nuclei  of  the  lymphatic  sheath  ; 
the  adventitia  is  also  affected.  The  nuclei  may  be  so 
crowded  together  that  nothing  else  can  be  seen.  Some- 
times, with  less  increase  of  nuclei,  the  adventitia  may 
be  thickened  and  may  have  longitudinal  striae.  !N^ext, 
the  muscular  elements  disappear  without  fatty  degen- 


88  DISEASES  OF  THE  £EAIK 

eration,  the  muscular  markings  on  tlie  artery  becoming 
less  distinct  and  fewer,  until  finally  they  disappear 
in  limited  regions ;  then  the  artery  may  dilate,  bulge 
out  locally,  and  a  minute  aneurism  is  formed;  some- 
times only  a  fusiform  swelling  of  the  artery  is  seen. 
These  miliary  aneurisms  may  be  very  numerous  through- 
out the  brain,  or  a  few  in  a  limited  region.  They  some- 
times seem  to  be  quite  large  from  the  staining  of  the 
tissue  immediately  around  them. 

They  are  found  with  most  frequency  in  the  corpus 
striatum  and  the  optic  thalamus,  then  in  the  pons  Va- 
rolii, and  the  gray  substance  of  the  convolutions.  These 
minute  aneurisms  bear  an  important  relation  to  cerebral 
heemorhage,  as  in  much  the  larger  number  of  cases  their 
rupture  is  the  cause  of  the  hgemorrhage. 

Atheromatous  degeneration  of  the  larger  arteries 
may  favor  a  rupture  by  impairing  the  elasticity  of  the 
vessels.  Increased  strength  in  the  action  of  the  heart 
will  also  act  as  a  cause  of  haemorrhage  by  sending  the 
blood  with  increased  force  into  the  diseased  vessels ; 
hence  many  cases  occur  while  the  patient  is  making 
violent  effort ;  but  also  many  occur  during  sleep. 

While  it  is  true  that  disease  of  the  kidneys  is  found 
in  many  instances  with  cerebral  haemorrhage,  it  is  not 
as  yet  determined  how  frequent  this  association  is. 

Some  writers  lay  stress  upon  a  vitiated  state  of  the 
blood  as  a  cause.  This  might  affect  the  nutrition  of 
the  arteries,  and  so  favor  the  disease. 

The  condition  of  the  brain  is  mentioned  as  another 
element  in  the  production  of  haemorrhage.  It  is  scarcely 
possible  for  periarteritis  with  many  miliary  aneurisms  to 
exist  without  interfering  with  the  nutrition  of  the  brain, 
:and  doubtless  many  of  the  so-called  premonitory  symp- 
toms are  thus  produced ;  but  how  much  such  change 
favors  the  occurrence  of  haemorrhage  we  have  no  means 
of  estimating.  Whether  such  changes  are  of  the  nature 
of  softening,  or  of  an  increase  of  the  interstitial  tissue, 
is  not  yet  known.    Minute  haemorrhages  are  sometimes 


CEREBRAL  EMMORREAOE.  89 

found  around  tumors  in  the  brain ;  generally  they  are 
very  small,  and  cause  no  special  symptoms. 

It  is  well  to  mention  that  cerebral  haemorrhage  oc- 
curs the  more  frequently  after  the  age  of  forty  years  ; 
but  it  is  also  found  in  infancy  ;  it  is  perhaps  more  com- 
mon in  winter  than  in  summer,  and  in  men  than  in 
women. 

Pathological  Aistatomy.  —The  changes  in  the  brain 
and  the  blood-vessels  predisposing  to  haemorrhage  have 
been  already  described  when  speaking  of  the  aetiology. 

The  blood  which  escapes  from  the  ruptured  artery 
forces  its  way  among  the  nerve-elements,  separating 
some,  tearing  apart  others,  sometimes,  if  the  clot  is 
large,  entirely  isolating  masses  of  cerebral  tissue  torn 
from  their  connections.  At  first  the  clot  is  dark  red, 
uniform  in  consistency,  resembling  any  other  clot  of 
blood.  In  a  few  hours  the  clot  is  somewhat  less  con- 
sistent, the  watery  constituents  are  absorbed,  the  color 
becomes  lighter  ;  finally  only  a  pale,  yellowish-colored 
remnant  with  a  few  blood-crystals  can  be  found.  The 
nervous  structures  which  have  been  torn  and  bruised 
undergo  fatty  degeneration,  there  is  more  or  less  soft- 
ening around  the  clot,  the  surrounding  structures  im- 
bibe the  coloring-matter  and  are  yellow,  and  granular 
corpuscles  and  fatty  degeneration  increase  the  extent 
of  this  colored  zone.  Inflammation  may  set  in  which 
will  destroy  extensive  tracts  of  brain-substance  and  aid 
in  bringing  about  the  fatal  termination. 

If  the  inflammation  is  slight  and  the  patient  sur- 
vives, the  cerebral  tissue  immediately  around  the  clot 
undergoes  a  fibrous  change,  the  interstitial  elements 
increase,  and  a  cyst  is  formed,  a  firm  wall  separating 
the  diseased  from  the  healthy  brain-substance.  If  the 
clot  is  small,  there  may  be  no  cyst ;  there  is  simply  a 
small  cicatrix  of  tough  connective  tissue.  Sometimes 
there  is  no  well-defined  cyst- wall,  the  wall  being  soft 
and  formed  of  a  mixture  of  fibrous  tissue  and  granular 
corpuscles  in  such  proportions  as  not  to  have  the  firm- 


90  DISEASES  OF  THE  BRAIN. 

ness  above  mentioned ;  then  this  character  of  tissue 
passes  imperceptibly  into  the  normal  cerebral  structure. 

When  the  haemorrhage  is  situated  so  as  to  implicate 
the  deeper  layers  of  the  cortex  and  the  white  substance 
beneath,  and  especially  the  anterior  two  thirds  of  the 
posterior  limb  of  the  internal  capsule,  a  secondary  de- 
generation appears  after  some  weeks  or  months,  follow- 
ing the  nerve-fibers,  through  the  crus  cerebri,  pons,  and 
medulla,  into  the  cord. 

According  to  Jaccoud,  the  clot  remains  soft  and 
homogeneous  during  three  to  five  days  ;  then  absorp- 
tion continues  to  the  tenth  or  twelfth  day.  After  fifteen 
or  twenty  days  the  clot  has  contracted  into  a  dense, 
solid  mass  of  a  yellowish  color,  quite  different  in  ap- 
pearance from  coagulated  blood.  The  new  formation 
around  the  clot  begins  generally  on  the  seventh  or 
ninth  day ;  toward  the  twentieth  the  cyst  is  formed, 
and  by  the  thirtieth  or  fortieth  the  limiting  membrane 
has  become  organized. 

Symptoms. — Premonitory  symptoms  will  be  recog- 
nized less  frequently  with  some  classes  of  patients  than 
with  others ;  the  less  observing  may  give  no  heed  to 
sensations  or  conditions  which  others  may  notice. 
Many  patients  have  for  a  short  time,  or  even  days  and 
weeks,  preceding  the  haemorrhage,  symptoms  which  are 
worthy  of  notice.  These  premonitory  symptoms  are 
very  important  as  indications  for  a  course  of  treatment 
to  ward  off  the  threatening  attack,  and  even  if  in  the 
majority  of  such  cases  no  attack  occurs,  yet  they  should 
never  be  neglected. 

Among  the  symptoms  which  precede  haemorrhage 
for  several  days  or  even  weeks,  the  most  common  are 
those  which  show  disturbance  of  the  circulation  or  nu- 
trition of  the  brain  ;  among  these  the  most  frequent  are 
sensorial  disturbances.  Oftentimes  there  have  been 
long-continued  symptoms  of  cerebral  hyperemia,  head- 
ache, or  sense  of  pressure  in  the  head,  dizziness,  dis- 
turbance of  eyesight,  noises  in  the  head,  pricking,  and 


CEREBRAL  HEMORRHAGE.  91 

numbness,  especially  in  the  fingers,  perhaps  also  in  the 
feet,  sometimes  on  one  side,  sometimes  on  both  ;  mental 
confusion,  slight  forgetfulness  of  words,  loss  of  mem- 
ory, and  change  in  disposition.  Owing  to  impaired 
motor  power  or  diminished  sensation,  there  is  a  loss  of 
delicacy  in  the  touch,  the  character  of  the  handwriting 
is  changed,  and  there  is  awkwardness  in  using  the 
hands. 

Sometimes,  if  severe  and  persistent,  especially  if  uni- 
lateral, these  symptoms  are  caused  by  slight  haemor- 
rhages which  may  precede  a  more  severe  one.  If  there 
has  been  a  heemorrhage  with  partial  recovery,  a  recur- 
rence of  these  symptoms  may  be  the  warnings  of  re- 
newed danger. 

Ophthalmoscopic  examination  may  occasionally 
show  the  presence  of  miliary  aneurisms,  dilatations  of 
the  retinal  arteries,  or  slight  retinal  haemorrhages,  and 
so  be  of  value  as  indicating  danger  from  the  rupture  of 
cerebral  arteries. 

The  symptoms  attending  the  rupture  of  a  blood- 
vessel in  the  brain  will  vary  according  to  the  locality  of 
the  lesion,  the  size  of  the  vessel,  and  the  rapidity  and 
force  with  which  the  blood  escapes.  It  is  easily  under- 
stood, therefore,  that  there  may  be  great  diversity  in 
the  initial  symptoms  as  well  as  in  the  subsequent  course 
of  the  case. 

The  severest  form  of  cerebral  haemorrhage  is  that 
which  may  be  called  apoplectic.  The  patient  suddenly 
loses  control  over  himself,  falls,  if  he  is  either  sitting  or 
standing,  and  soon  entirely  loses  consciousness.  At  the 
same  time  reflex  action  of  the  limbs  is  abolished,  and, 
unless  there  are  convulsions,  the  patient  lies  limp  and 
inert,  simply  breathing  and  swallowing  if  the  substance 
is  put  far  enough  back  in  the  fauces  to  excite  the  in- 
voluntary muscles  of  deglutition,  though  occasionally 
even  these  fail  to  act.  The  respiration  may  become 
noisy  from  the  paralysis  of  the  soft  palate  or  from  the 
accumulation  of  mucus  in  the  bronchi ;   at  first  the 


92  DISEASES  OF  TEE  BRAIN. 

countenance  is  generally  pale,  but,  if  respiration  is  in- 
terfered with,  it  becomes  dusky  red.  The  cheeks  flap 
back  and  forth  with  every  respiration,  passively  follow- 
ing the  current  of  air.  The  shortest  time  on  record  be- 
fore death  under  these  circumstances  is  five  minutes ; 
more  frequently  from  half  an  hour  to  several  hours 
elapse  before  the  fatal  termination. 

The  attack,  as  above  described,  is  far  from  common ; 
much  more  frequently  there  is  a  gradual  development 
of  the  symptoms ;  the  patient  is  conscious  that  some- 
thing is  amiss,  and  may  try  to  rise  from  his  chair,  may 
be  able  to  reach  the  bed  or  sofa,  or,  finding  himself 
unable  to  hold  articles  in  his  hands,  turns  to  speak  to 
a  friend  and  can  not  make  himself  understood.  Soon 
he  sinks  powerless,  and  passes  gradually  into  coma, 
which  is  not  so  extreme  but  that  he  can  be  aroused  by 
a  loud  voice,  or  a  powerful  irritation  may  give  rise  to 
expressions  of  pain.  Reflex  movements  generally  per- 
sist. The  unconsciousness  may  continue  only  a  few 
minutes,  or  may  persist  much  longer — even  until  death. 

During  the  unconscious  stage  the  physician  can 
often  recognize  that  one  side  is  paralyzed.  •  The  mouth 
is  drawn  to  one  side,  the  limbs  on  one  side  are  stiff er 
than  on  the  other,'  or  half  voluntary  movements  are 
made  only  with  one  side ;  a  strong  irritation  causes 
movements  only  on  one  side.  But  little  can  be  learned 
from  the  condition  of  the  pupils,  as  they  are  very  vari- 
able ;  but  many  times  the  eyes  are  turned  continuously, 
both  toward  the  same  side,  and  the  head  is  rotated  with 
the  face  toward  that  side.  This  phenomenon  is  not  of 
long  duration  ;  it  is  seen  in  only  a  small  proportion  of 
patients,  but,  when  present,  it  is  valuable  as  indicating 
serious  organic  lesion,  and  may  aid  in  deterrnining  its 
location.     (See  above,  p.  44.) 

After  the  return  of  consciousness  ifc  will  be  noticed 
that  there  is  hemiplegia,  generally  affecting  both  the 
arm  and  the  leg.  This  paralysis  may  be  complete, 
total  loss  of  power ;  cutaneous  reflex  action  is  usually 


CEREBRAL  HEMORRHAGE.  93 

lost  on  the  paralyzed  side ;  after  a  few  hours  or  few- 
days  power  of  motion  returns,  by  degrees  one  act  after 
another  can  be  performed ;  usually  the  legs  gain  the 
most  rapidly,  the  more  complicated  action  of  the  arms 
and  hands  being  recovered  later,  Hughlings  Jackson 
has  formulated  the  proposition  that  the  most  instinct- 
ive, automatic  actions  are  the  first  to  return. 

The  patient  may  continue  to  improve  in  his  power 
of  using  his  limbs  for  many  months ;  perhaps  to  a  casual 
observer  there  is  finally  complete  recovery  ;  but  more 
frequently  a  stage  is  finally  reached  after  which  no  fur- 
ther improvement  can  be  expected ;  the  limbs  on  one 
side  are  weak  ;  certain  motions  can  not  be  performed, 
or  are  executed  only  with  difficulty  and  imperfectly ; 
there  is  hemi-paresis. 

The  muscles  of  the  face  are  often  affected,  and  im- 
mediately after  the  attack  the  mouth  is  drawn  to  the 
ojDposite  side,  the  naso -labial  fold  being  more  marked 
on  that  side.  The  nerve-fibers  which  supply  the  upper 
part  of  the  face — the  orbicularis  palpebrarum,  the  front- 
al and  corrugator  supercilii  muscles — usually  are  not 
affected.  Nothnagel  states  that,  when  the  tract  of 
nerve-fibers  passing  along  the  base  of  the  nucleus  len- 
ticularis  is  involved,  the  above  muscles  are  paralyzed. 
They  may  be  paralyzed  also  if  the  lesion  is  in  the  lower 
part  of  the  pons. 

JJ^othnagel  also  states  that  the  muscles  of  the  trunk 
are  generally  partially  paralyzed. 

Speech  may  be  interfered  with  ;  the  more  frequent- 
ly from  loss  of  power  over  the  organs  of  speech,  the 
muscles  of  the  throat,  and  mouth  and  tongue.  Only 
occasionally  is  there  aphasia  when  the  right  side  is  af- 
fected. This  is  a  much  more  frequent  symptom  in  em- 
bolism. 

On  the  second  to  the  fourth  day  after  the  attack 
symptoms  may  develop  showing  that  there  is  an  inflam- 
matory process  around  the  clot.  There  is  headache, 
confusion  of  thought,  feverishness,  contraction  of  the 


94  DISEASES  OF  TEE  BRAIN. 

paralyzed  limbs,  sometimes  slight  convulsions.  The 
duration  of  this  stage  is  variable,  from  a  few  to  several 
days ;  sometimes  these  symptoms  recur  two  or  three 
times  or  more. 

Bourneville,  considering  the  temperature,  divides 
cases  of  cerebral  haemorrhage  into  three  clases  :  1.  Ful- 
gurant  or  multiple  haemorrhages,  death  occurring  in  a 
very  few  hours,  with  initial  depression  of  temperature. 
2.  Cases  ending  in  death  in  ten,  fifteen,  twenty  hours, 
initial  depression  lasting  only  one  to  three  hours  or  so, 
and  subsequent  rapid  and  considerable  elevation  of 
temperature.  3,  Cases  ending  in  death  only  after  sev- 
eral days  ;  initial  depression  of  short  duration  ;  then  a 
stationary  period,  continuing  two  to  four  days,  with  a 
primary  slight  elevation  and  subsequent  oscillation 
about  the  normal ;  finally  an  ascending  period.  Dur- 
ing the  initial  period  of  depression  the  pulse  and  res- 
piration are  but  little  changed.  If  the  patient  is  to 
recover,  the  ascending  period  is  of  brief  duration,  and 
the  temperature  does  not  rise  very  high,  or  it  is  entirely 
wanting. 

The  above  description  refers  to  cases  of  severe  cere- 
bral haemorrhage  with  loss  of  consciousness.  In  many 
cases  there  are  no  comatose  symptoms.  The  patient 
more  or  less  gradually  loses  power  over  one  side,  and 
falls  with  consciousness  intact.  The  paralysis  may  be 
as  complete,  and  the  recovery  of  motion  may  occur  in 
the  same  order,  as  in  the  other  class  of  cases.  After  a 
first  attack  with  the  consciousness  preserved,  a  second 
may  occur  soon  in  which  that  faculty  is  lost. 

Yet  lighter  attacks  occur  in  which  there  is  only  a 
slight  impairment  of  motion  in  only  one  or  more  limbs, 
or  the  attack  may  be  confined  to  the  face.  There  are 
all  degrees  of  severity,  from  the  very  lightest  to  the 
most  complete. 

Disturbance  of  sensation  is  not  so  common  as  that 
of  motion.  At  first,  indeed,  sensation  may  be  abolished, 
but  it  is  more  quickly  recovered.     Generally  all  varie- 


CEREBRAL  EJEMORRHAGE.  95 

ties  of  sensation  are  equally  affected.  Occasionally 
other  parts  than  those  whose  motion  is  lost  show 
diminution  of  sensation.  Sometimes  there  is  a  persist- 
ent change  of  sensation,  which  is  perhaps  not  always 
sought  for.  An  object  is  perceived  on  both  sides,  but 
the  impression  is  less  acute  on  the  affected  side,  or  con- 
tact with  the  object  excites  also  a  peculiar  tingling  sen- 
sation besides  the  usual  sense  of  touch.  Sometimes 
there  is  increased  sensitiveness  to  painful  impressions. 

Ollivier  has  found  in  many  cases  a  change  in  the 
urinary  secretion  after  cerebral  haemorrhage.  There  is 
first  an  increased  secretion  of  urine,  and  albumen  is 
found  in  it ;  later  sugar  may  be  found.  These  changes 
occur  almost  immediately  after  the  attack  and  continue 
only  twelve  to  twenty-four  hours ;  they  are  not  depend- 
ent upon  the  locality  of  the  lesion. 

Cutaneous  reflexes  may  remain  diminished  or  lost 
on  the  side  affected.  Tendon  reflex  is  often  exagger- 
ated, especially  after  contractures  have  appeared. 

Dr.  Sanders  has  written  upon  haemorrhages  into  the 
ventricles,  separating  such  cases  from  both  cerebral  and 
meningeal  hgemorrhages.  He  has  collected  ninety-four 
cases  of  such  primary  haemorrhages,  and  considers 
their  aetiology  and  pathology,  which  differ  little  from 
those  of  other  cerebral  haemorrhages.  The  diagnostic 
symptoms  he  mentions  are  suddenness  of  the  attack 
without  premonitory  symptoms  ;  convulsions  in  the  be- 
ginning, or  later ;  partial  or  complete  coma,  paralysis, 
contracture,  dilated  or  contracted  pupils.  Death  usu- 
ally occurs  early,  generally  within  twelve  hours  ;  a  few 
patients  recover.  The  above  symptoms  are  almost  ex- 
actly those  found  in  any  case  of  severe  cerebral  haemor- 
rhage. A  positive  diagnosis  is  in  many  or  most  cases 
impossible. 

An  explanation  of  the  phenomena  attending  cere- 
bral haemorrhage  will  aid  to  a  clearer  understanding  of 
the  subject,  and  will  be  of  value  in  determining  treat- 
ment. 


96  DISEASES  OF  THE  BRAIK 

Several  explanations  have  been  given  of  tlie  initial 
loss  of  consciousness,  the  more  important  of  which  are, 
that  by  Niemeyer,  who  refers  it  to  cerebral  anaemia 
caused  by  compression  of  capillaries ;  that  by  Trousseau 
and  Jaccoud,  and  Jackson  referring  it  to  shock.  The 
shock  is  direct  on  the  side  of  the  haemorrhage,  is  trans- 
mitted or  reflex  on  the  other. 

Nothnagel,  after  reviewing  these  and  other  theories, 
says:  "We  find  ourselves,  then,  finally,  obliged  to  ad- 
mit that  the  physiological  relations  of  hgemorrhagic 
apoplexy  have  not  yet  been  made  so  clear  as  is  com- 
monly believed." 

The  most  reasonable  explanation  seems  to  be  that 
there  is  both  shock  with  consequent  exhaustion,  and 
anaemia,  not  simply  from  compression  of  vessels,  but 
also  from  reflex  contraction. 

The  paralysis,  both  of  motion  and  sensation,  is  the 
result  of  the  direct  injury,  of  the  shock,  of  the  local  or 
general  anaemia  from  compression  of  the  smaller  ves- 
sels, the  tearing  across  of  others,  of  the  oedema,  the  in- 
filtration of  the  surrounding  cerebral  substance  with 
serum  absorbed  from  the  effused  blood,  this  oedema 
also  giving  rise  to  anaemia.  It  is  impossible  to  decide 
how  large  a  share  belongs  to  each  of  these  elements  in 
producing  the  patient's  condition  a.t  the  moment  of  re- 
covery of  consciousness.  The  influence  of  shock  and 
anaemia  due  to  compression  from  the  size  of  the  clot 
pass  off  soonest.  The  anaemia  due  to  the  oedema  will 
slowly  disappear ;  as  the  liquid  parts  of  the  clot  are  ab- 
sorbed, the  uninjured  nerve-fibers  surrounding  the  clot 
gradually  regain  their  function.  Another  probable 
source  of  improvement  is  found  in  the  possibility  that 
functions  performed  by  the  destroyed  nerve-elements 
may  be  acquired  by  those  of  other  parts  of  the  brain,  so 
that  in  time  there  seems  to  be  very  little  paralysis  re- 
maining. Also  patients  learn  to  use  to  the  greatest  ad- 
vantage the  power  which  remains.  One  cause  of  delay 
in  recovery  may  be  found  in  the  functional  inertia  of 


CEREBRAL  HAEMORRHAGE.  97 

long  disused  nerve-fibers,  so  that  even  after  organic 
restoration  there  may  still  be  a  period  of  diminished 
functional  activity.  Finally,  it  is  not  unlikely  that 
many  injured  nerve-elements  heal,  and  nerve-fibers 
which  have  been  ruptured  or  bruised  may  recover  their 
organic  integrity.  After  these  processes  of  repair  have 
gone  to  their  utmost  limits,  there  must  still  be  a  very 
large  number  of  nerve-elements  destroyed  beyond  pos- 
sibility of  recovery.  If,  then,  the  haemorrhage  is  so  situ- 
ated that  these  elements  are  necessary  for  perfect  mo- 
tion and  sensation,  there  will  be  a  residuum  of  paralysis 
from  which  it  is  utterly  useless  to  expect  recovery. 

As  a  result  of  the  imperfect  healing  of  the  torn 
nerve-fibers,  a  certain  amount  of  paralysis  remains  per- 
manently. After  a  few  months — two  to  four — a  stiff- 
ness of  the  paralyzed  limbs  is  noticeable  ;  there  is  a 
certain  amount  of  contraction.  The  degree  of  the  con- 
traction varies  from  a  scarcely  perceptible  stiffness  of 
the  fingers  to  a  firm  closure  of  the  hand,  with  flexion 
at  the  elbow  and  adduction  of  the  arm.  The  upper  ex- 
tremity is  more  frequently  affected  than  the  lower ;  the 
lower  is  rarely  affected  alone.  The  flexor  muscles  are 
almost  invariably  the  ones  affected.  At  first  the  resist- 
ance of  the  contracted  muscles  is  easily  overcome,  and 
during  sleep  the  muscles  relax  spontaneously.  On  first 
waking,  the  hand  is  as  supple  as  the  other  ;  involuntary 
motions  of  stretching  and  yawning  may  be  made  by  it 
in  unison  with  the  unparalyzed  hand.  Soon,  however, 
as  voluntary  actions  are  performed,  the  contraction  re- 
appears, to  persist  until  the  patient  again  sleeps.  Pa- 
tients and  their  friends  are  often  encouraged  by  this 
relaxation.  It  is  far  from  being  a  favorable  indication, 
and  should  never  deceive  the  physician.  Eventually 
the  contraction  may  become  persistent  even  during 
sleep. 

These  contractures  must  be  distinguished  from  those 
which  occur  earlier,  either  at  the  time  of  the  attack 
and  soon  disappear,  or  a  few  days  after,  at  about  the 
1 


98  DISEASES  OF  THE  BRAIK 

time  when  inflammatory  action  arises  around  the  clot. 
These  also  disappear  within  a  short  time.  These  latter 
varieties  have  been  explained  by  supposing  a  direct 
irritation  from  the  clot  or  from  the  subsequent  inflam- 
matory processes.  The  first  variety  of  contraction  has 
been  explained,  by  Charcot  and  others,  by  the  presence 
of  secondary  degeneration  in  the  lateral  columns  of  the 
spinal  cord. 

Associated  movements,  interesting  to  observe,  are 
often  seen  in  hemiplegic  patients.  After  the  partial  re- 
turn of  voluntary  motion,  if  the  patient  tries  to  move 
the  paralyzed  limb,  the  unaffected  limb  will  involun- 
tarily perform  the  same  motion.  It  would  seem  that 
the  motor  impulse  required  to  act  on  the  partially  par- 
alyzed muscles  needs  to  be  so  great  to  overcome  the 
resistance  offered  by  the  injured  nerve-fibers  that  the 
lower  motor  centers  on  the  opposite  side  are  also  set  in 
action,  the  impulse  crossing  by  the  commissures  to  the 
unaffected  side. 

In  many  cases  of  cerebral  haemorrhage,  after  a  par- 
tial recovery  of  motion,  the  effort  to  perform  an  action 
gives  rise  to  irregular  contraction  of  the  muscles  of  the 
paralyzed  limb  which  may  resemble  chorea,  or  when 
the  will  is  not  exercised  there  may  be  slow,  irregular,  or 
more  rapid  movements  of  the  partially  paralyzed  mus- 
cles. These  post-hemiplegic  movements  are  well  de- 
scribed by  Gowers.  They  vary  from  a  very  slight  mo- 
tion of  the  fingers  to  an  almost  constant  motion  of  the 
whole  arm,  and  even  of  the  toes  and  leg.  Among  these 
movements  is  that  which  has  been  named  athetosis  by 
Hammond,  which  is  more  frequently  seen  after  hemi- 
plegia occurring  in  infancy,  but  may  also  occur  in 
adult  life. 

More  rarely  there  is  sometimes  seen  a  reflex  tremor 
on  the  healthy  side,  occurring  whenever  the  affected 
limb  is  moved. 

The  mental  faculties  are  almost  always  impaired 
after  cerebral  haemorrhage.     In  severe  cases,  of  course, 


CEREBRAL  HEMORRHAGE.  99 

these  are  at  first  entirely,  or  almost  entirely,  destroyed  ;. 
but  even  in  liglit  cases  it  is  soon  noticed  that  patients 
are  very  diiferent  in  disposition  and  intellectual  power. 
They  are  irritable  and  emotional,  easily  angry,  or  easily 
bursting  into  tears.  One  who  has  been  very  guarded 
in  the  use  of  language  may,  on  slight  provocation,  or 
with  no  provocation,  break  out  into  oaths.  The  emo- 
tional excitement  is  almost  exclusively  associated  with 
left  hemiplegia.  Memory  may  be  more  or  less  defect- 
ive. Even  after  almost  perfect  recovery  some  impair- 
ment of  mental  power  may  remain  so  as  to  render  the 
patient  unfit  to  carry  on  his  business  without  assist- 
ance, and  he  may  be  so  obstinate  and  suspicious  as  to 
render  it  advisable  for  him  to  give  up  all  attempts  to 
continue  in  business. 

The  paralysis  is  usually  confined  to  one  side  of  the 
body,  the  face,  arm,  and  leg  being  affected  on  the 
same  side,  but  on  the  side  opposite  the  seat  of  the 
haemorrhage.  This  is  the  common  and  regular  form, 
a  complete  hemiplegia,  and  in  these  cases  usually  the 
upper  branches  of  the  facial  nerve  are  not  affected. 
There  are,  however,  occasional  irregular  forms.  What 
has  been  said  in  regard  to  localization  of  cerebral  lesions 
will  aid  in  diagnosticating  the  seat  of  the  haemorrhage 
in  these  cases.  Occasionally  all  four  limbs  are  para- 
lyzed, either  from  multiple  haemorrhages  or  from  large 
effusions  into  the  pons  and  medulla.  Such  cases  are 
rapidly  fatal.  In  a  very  few  cases  the  paralysis  has 
been  found  to  be  on  the  same  side  with  the  haemor- 
rhage. Sometimes  the  arms  are  affected  on  one  side, 
the  legs  on  the  opposite  side.  Occasionally  only  the 
cranial  nerves  are  affected,  or  only  the  arm  is  paralyzed. 

Acute  bed-sores  may  form  two  to  four  days  after 
the  attack.  They  are  situated  on  the  paralyzed  side, 
over  the  glutei  muscles.  Bed-sores  may  appear  at  a 
later  period,  being  developed  more  gradually.  They 
may  occur  on  the  knee  or  the  heel,  and  are  perhaps 
more  frequent  in  elderly  patients  than  in  younger. 


100  DISEASES  OF  THE  BEAIK 

An  eruption  of  herpes  has  been  known  in  several 
cases  to  follow  cerebral  hsemorrhage,  the  eruption  fol- 
lowing the  distribution  of  certain  nerves.  The  skin 
may  undergo  a  thickening,  amounting  to  hypertrophy. 
There  is  frequently  more  or  less  oedema  of  the  para- 
lyzed hand,  sometimes  of  the  foot.  The  nutrition  of 
the  nails  and  hair  may  also  be  interfered  with  on  the 
affected  side. 

An  acute  inflammation  of  the  joints  has  been  ob- 
served following  cerebral  haemorrhage.  This  is  devel- 
oped first  fifteen  days  or  a  month  after  the  attack, 
about  the  time  when  the  late  contraction  appears.  The 
swelling,  redness,  and  articular  pains  are  sometimes  as 
marked  as  in  acute  articular  rheumatism.  The  affec- 
tion of  the  joints  is  limited  to  the  paralyzed  limbs. 

The  general  nutrition  of  the  paralyzed  muscles  does 
not  seriously  suffer  in  adults,  and  there  is  no  degenera- 
tion. When  cerebral  haemorrhage  occurs  in  children 
there  may  be  subsequent  retarded  development.  Two 
cases  have  been  reported  in  which  there  was  muscular 
atrophy,  with  secondary  degeneration  of  the  cells  of  the 
anterior  cornu.*  As  a  rule,  also,  the  electrical  reaction 
of  both  nerves  and  muscles  for  both  the  faradic  and 
galvanic  currents  is  unchanged.  Once  in  a  while  there 
may  be  a  slight  diminution,  occasionally  a  slight  in- 
crease in  the  irritability. 

DiAGisrosis. — Haemorrhage  into  the  substance  of  the 
brain  is  to  be  distinguished  from  meningeal  haemor- 
rhage, from  thrombosis  and  embolism  of  a  cerebral  ar- 
tery. The  diagnosis  from  these  will  be  considered  un- 
der those  divisions. 

While  the  patient  is  nnconscious  there  may  arise  a 
doubt  whether  the  coma  is  due  to  haemorrhage  or  to 
poisoning  by  alcohol,  opium,  or  whether  it  is  a  case  of 
nraemic  poisoning. 

The  odor  of  alcohol  may  be  recognized  in  the  breath, 

*  See  Pitres  in  "  Arch,  de  Physiol.,"  1876,  p.  657 ;  and  "  Charcot's 
Lectures,"  t.  i,  p.  55. 


CEREBRAL  HEMORRHAGE.  101 

or,  if  there  is  vomiting,  in  the  vomitus ;  but  this  does 
not  exclude  cerebral  hsemorrhage.  If,  on  examination, 
unilateral  symptoms  appear,  and  especially  if  there  is 
conjugate  deviation  of  the  eyes  and  rotation  of  the 
head  to  the  same  side  to  which  the  eyes  are  turned, 
the  diagnosis  is  made  easier.  The  course  of  the  tem- 
perature, at  first  lowered  for  an  hour  or  so,  then  rising, 
will  indicate  haemorrhage. 

The  diagnosis  from  opium  poisoning  may  be  made, 
in  part  by  the  above-mentioned  symptoms,  also  by  the 
more  gradual  advent  and  increase  of  the  coma.  The 
fact  of  there  being  convulsions  would  exclude  opium 
poisoning.  The  state  of  the  pupils  could  not  be  de- 
pended upon,  as  they  may  be  contracted  in  hsemor- 
rhage,  and  are  occasionally  dilated  in  opium  poisoning, 
especially  just  before  death. 

Uremic  poisoning  is  at  times  equally  difiicult  to 
recognize.  The  unilateral  character  of  the  symptoms 
will  generally  aid  here,  though  not  always.  The  pres- 
ence of  albumen  in  the  urine  will  not  necessarily  ex- 
clude haemorrhage,  for  in  many  cases  of  Bright's  dis- 
ease this  accident  occurs  ;  yet,  from  the  history  of  the 
case  and  the  condition  of  the  patient,  a  probable  opinion 
may  be  formed. 

Epileptic  convulsions  may  be  very  slight  and  the 
succeeding  coma  deep,  so  as  to  give  rise  to  doubt 
whether  there  has  not  been  cerebral  haemorrhage.  Oc- 
casionally in  epilepsy  there  is  conjugate  deviation  of 
the  eyes  and  rotation  of  the  head  ;  also  once  in  a  while 
the  attack  is  unilateral,  and  there  remains  a  temporary 
paralysis  afterward.  The  history  of  previous  similar 
attacks,  with  rapid  recovery  from  the  paralysis,  may 
clear  up  the  doubt ;  but  if  this  is  wanting,  it  may  be 
impossible  to  come  to  a  satisfactory  conclusion.  These 
cases  of  epilepsy  are,  however,  very  rare,  and  generally 
the  diagnosis  is  not  difficult. 

Hemiplegia  may  be  assumed  with  a  desire  to  de- 
ceive, as  in  a  suit  for  damages  after  an  injury.     The  ig- 


102  DISEASES  OF  THE  BRAIW. 

norance  of  such  persons  usually  gives  rise  to  inconsist- 
encies in  their  account  of  the  symptoms.  The  pre- 
tended contraction  is  not  like  the  real.  Associated 
movements  on  the  healthy  side  do  not  occur  vs^hen 
an  effort  is  made  to  move  the  affected  limb.  Almost 
always  the  true  hemiplegic  will  endeavor  to  aid  the 
disabled  hand  with  the  well  hand,  or  the  body  will  be 
inclined  to  act  as  a  fulcrum  to  help  raise  the  arm.  The 
pretender  does  not  do  this, 

Jastrowitz '"  states  that  pressing  the  greater  saphe- 
nous nerve  about  a  hand's  breadth  above  the  internal 
condyle  of  the  femur  causes  the  testicle  to  rise  on  the 
healthy  side,  but  has  no  effect  on  the  hemiplegic  side. 
It  has  been  said  that  other  reflex  acts  also  do  not  take 
place  on  the  hemiplegic  side.  When  the  skin  is  ex- 
posed there  is  no  goose-flesh  ;  tickling  the  nostril  does 
not  produce  sneezing  ;  touching  the  eyelashes  does  not 
cause  winking.  If  there  should  be  a  difference  be- 
tween the  two  sides  in  these  respects,  a  diagnosis  as 
between  narcotic  poisoning  or  simulation  and  cere- 
bral lesion  could  be  made  ;  but  whether  that  lesion  is  a 
hsemorrhage  or  some  other  must  depend  on  other  data. 

During  the  earlier  hours  or  days  the  attempt  to  lo- 
calize the  lesion  will  often  be  useless.  It  is  not  imtil 
the  effects  of  the  shock  and  pressure  of  the  clot  have 
passed  away  that  the  more  permanent  symptoms  can 
be  recognized,  and  these  must  chiefly  be  considered  in 
localizing  the  lesion. 

Peognosis. — During  the  comatose  stage,  soon  after 
the  attack,  it  is  impossible  to  form  any  opinion  as  to 
how  severe  the  attack  will  prove  ;  but  the  longer  this 
stage  continues  the  less  favorable  the  prognosis,  and  if 
it  lasts  beyond  forty-eight  hours  there  is  very  little 
probability  of  recovery.  If  the  attack  is  accompanied 
with  severe  convulsions,  which  are  not  due  to  epilepsy, 
the  prognosis  is  the  more  serious,  as  the  convulsions 
attend  large  hsemorrhages — those  w^hich  burst  into  the 

*  "Berlin,  kl.  Wochenschrift,"  1875,  No.  31. 


CEREBRAL  HEMORRHAGE.  103 

ventricles  and  those  wMch.  are  situated  in  the  pons  and 
medulla.  The  occurrence  of  Cheyne-Stokes  respiration 
is  of  unfavorable  augury. 

There  is  a  form  of  attack  which  has  been  called  in- 
gravescent, which  is  always  fatal.  With  prodromic 
symptoms,  coma  gradually  comes  on,  or  there  is  a  sud- 
den loss  of  consciousness  of  short  duration,  after  which 
intelligence  is  partially  or  entirely  recovered,  to  be 
gradually  lost  again ;  the  coma  steadily  deepens,  and 
paralysis  becomes  more  and  more  complete.  The  symp- 
toms steadily  increase  in  severity  until  the  patient  lies 
helpless  and  senseless,  simply  breathing,  not  to  be 
aroused  by  any  form  of  irritation.  These  cases  are 
hopeless  ;  the  hsemorrhage  occurs  from  one  of  the 
larger  vessels  between  the  lenticular  nucleus  and  the 
external  capsule,  the  nerve-fibers  are  pressed  apart,  not 
many  are  torn  asunder ;  hence  the  earlier  symptoms  are 
slight. 

After  the  initial  depression  of  temperature,  if  the 
patient  survives  and  the  temperature  steadily  rises,  the 
prognosis  is  unfavorable.  If  there  is  a  slight  rise  and 
then  a  stationary  period  varying  but  little  from  100°, 
after  which  another  rise  of  temperature,  then  the  prog- 
nosis is  unfavorable  again.  If  the  temperature  does 
not  rise  a  second  time,  or  falls  to  normal,  the  prognosis 
is  favorable.  When  polyuria,  albuminuria,  and  glyco- 
suria exist  in  a  very  marked  degree,  the  prognosis  is 
grave. 

During  the  period  of  inflammatory  reaction  the 
prognosis  depends  upon  the  intensity  of  the  fever  and 
attendant  symptoms. 

Acute  bed-sores  appearing  shortly  after  the  attack 
are  extremely  unfavorable,  and  are  almost  certain  to  be 
followed  by  death. 

If  the  patient  survives,  a  complete  recovery  is  rarely 
to  be  expected.  Trousseau  considers  that  if  the  motor 
power  returns  in  the  leg  first,  before  the  arm,  the  prog- 
nosis is  more  favorable,  at  least  for  retention  of  mental 


104  DISEASES  OF  THE  BRAIN. 

power.  Recovery  of  motion  may  progress  slowly  for 
an  indefinite  period.  If  the  late  contraction  appears, 
there  is  little  or  no  chance  of  further  improvement,  and, 
in  regard  to  disappearance  of  the  contraction,  the  prog- 
nosis is  absolutely  unfavorable. 

A  second  attack  may  occur  in  any  one  who  has  suf- 
fered from  a  cerebral  haemorrhage.  If  there  is  evident 
disease  of  the  arteries,  Bright's  disease,  or  retinal  haem- 
orrhages, this  is  more  likely  to  occur.  Also,  if  the  pa- 
tient be  past  middle  life,  there  is  more  probability  of 
another  attack.  After  an  attack,  a  return  of  prodromic 
symptoms  would  indicate  renewed  danger. 

Teeatmeistt. — When  the  physician  first  sees  a  pa- 
tient attacked  with  cerebral  haemorrhage,  the  injury 
has  probably  been  done  ;  in  most  cases  the  blood  has 
ceased  to  escape  from  the  ruptured  vessel.  Trousseau 
advocates  very  strongly  to  let  the  patient  alone  ;  others 
advise  bleeding  (Jaccoud,  Huguenin)  under  certain  con- 
ditions. If  the  patient  is  hearty,  robust,  with  a  strong- 
ly acting  and  healthy  heart,  and  is  evidently  suffering 
from  too  great  blood-pressure  in  the  cranial  cavity, 
they  advocate  general  bleeding  as  the  most  effectual 
means  of  relieving  this  excessive  blood  -  pressure. 
Bleeding  is  not  indicated  where  the  pulse  is  weali,  if 
the  patient  is  aged  or  feeble,  or  if  there  is  heart  dis- 
ease, or  when  the  coma  has  been  of  short  duration  and 
consciousness  has  returned.  Practically,  very  few  cases 
are  suitable  for  bleeding  under  these  conditions.  In  by 
far  the  larger  number  of  cases  nothing  can  be  done  ex- 
cept to  place  the  patient  on  a  bed  with  the  head  rather 
elevated,  loosen  all  the  clothing,  and  wait.  As  perfect 
quiet  as  possible  should  be  maintained,  the  patient  not 
moved,  and  fed  with  the  simplest  diet :  if  previously  in 
full  health  and  well  nourished,  it  will  be  no  disadvan- 
tage to  feed  sparingly ;  if  in  poor  health  and  ill  nour- 
ished, the  feeding  should  be  more  abundant.  If  the 
heart's  action  is  feeble  and  there  is  evident  lack  of  vi- 
tality, stimulants,  at  first  external,  afterward,  if  neces- 


CEREBRAL  HyEMORRHAGE.  105 

sary,  internal,  should  be  used.  After  return  of  con- 
sciousness no  special  medical  treatment  is  needed  until 
the  period  of  inflammatory  reaction,  when  cold  to  the 
head,  a  laxative  to  open  the  bowels,  and,  if  there  is 
much  headache,  chloral,  or  some  preparation  of  opium 
or  belladonna,  to  relieve  the  x)ain.  Occasionally,  dry 
cups  to  the  back  of  the  neck  or  local  bleeding  may  be 
called  for.  Ergot,  by  mouth  or  subcutaneously,  may 
be  used  to  diminish  the  danger  of  renewed  haemorrhage. 

After  the  danger  from  inflammatory  reaction  is 
passed,  many  times  there  will  be  necessity  for  medical 
treatment.  The  patient  should  be  kept  quiet,  secluded, 
in  a  well- ventilated  apartment,  with  proper  regard  for 
all  hygienic  influences ;  should  have  a  plain,  unstimu- 
lating  diet,  not  half  starved,  but  should  receive  suffi- 
cient food.  After  a  few  weeks  the  nutrition  of  the 
muscles  would  be  benefited  by  systematic  rubbing, 
massage  ;  later,  after  five  or  six  weeks,  electricity  may 
be  used.  If  proper  care  is  exercised  in  not  using  too 
strong  a  current,  and  not  continuing  the  application 
too  long,  this  agent  may  be  used  without  danger,  and 
even  with  benefit,  earlier  than  many  authors  advise  it. 
The  galvanic  current,  using  from  three  or  four  to  twelve 
cells,  may  be  applied  to  the  head — one  electrode  on  the 
upper  cervical  vertebrse,  the  other  over  the  mastoid 
process,  or  just  below — or  one  pole  on  each  side  of  the 
head,  the  positive  on  the  same  side  with  the  haemor- 
rhage. Great  care  is  to  be  taken  not  to  suddenly  inter- 
rupt the  current,  to  use  it  only  one  minute,  or  at  most 
two ;  to  use  a  current  which  will  not  cause  dizziness. 
Whether  any  benefit  is  ever  obtained  by  this  use  of  the 
galvanic  current  is  extremely  doubtful,  and  it  is  men- 
tioned entirely  upon  the  authority  of  several  European 
observers. 

The  application  of  the  induced  or  faradic  current 
locally  is  attended  with  less  risk,  and  is  many  times  of 
positive  benefit.  One  pole  may  be  placed  on  some  in- 
different point,  and  the  other  passed  lightly  over  the 


106  DISEASES  OF  THE  BRAIN. 

different  muscles,  tlie  current  being  graduated  so  as  to 
cause  the  muscles  to  contract  slightly  without  pain. 
The  weakest  current  which  will  do  this  is  strong  enough. 
It  is  not  necessary  to  move  the  limbs.  The  application 
should  not  exceed  half  a  minute  to  a  minute  for  each 
muscle,  and  this  not  continuously,  but  one  muscle  after 
another  may  be  exercised  for  a  few  seconds,  and  then 
the  limb  be  gone  over  again.  This  application  will  have 
the  advantage  of  sustaining  the  nutrition  of  the  mus- 
cles ;  also,  the  muscles  would  not  fall  into  a  state  of 
sluggishness  from  simple  inertia.  Sometimes  it  will  be 
found  that  electricity  does  harm  ;  then,  of  course,  it 
should  be  immediately  omitted. 

During  the  period  of  gradual  recovery  little  can  be 
done  in  the  way  of  medication ;  absorption  and  resti- 
tution of  structure  and  function  advance  slowly.  For- 
merly, and  even  now,  strychnia  has  been  given  very 
freely.  It  is  not  of  sufficient  benefit  to  offset  the 
danger  arising  from  its  use  in  these  cases.  The  absorb- 
ent projoerties  of  iodide  of  potassium  render  that  drug 
acceptable,  but  with  care  not  to  disturb  the  stomach. 
Occasionally,  especially  in  syphilitic  cases,  mercury  has 
seemed  of  value.  After  the  occurrence  of  late  contrac- 
tion, little  or  no  improvement  need  be  expected  ;  though 
some  cases  are  reported  of  benefit  from  electricity  in 
these  cases,  I  have  never  seen  any. 

As  pneumonia  and  bronchitis  are  especially  liable  to 
attack  the  lung  on  the  affected  side,  especial  care  should 
be  taken  after  an  attack  to  avoid  exposing  the  patient. 

After  an  attack  the  patient  is  anxious  to  guard 
against  its  recurrence.  All  measures  necessary  to  sus- 
tain perfect  health  are  in  place — the  avoidance  of  what- 
ever will  produce  an  increase  of  pressure  in  the  cerebral 
blood-vessel,  a  quiet,  composed  life,  with  recreation  and 
amusement  sufficient  for  healthy  action  of  the  mind 
without  excitement.  If  in  active  business,  the  activity 
should  be  moderated. 


CHAPTER  yi. 

OCCLTJSIO:?^   OF   CEEEBEAL   ARTERIES. 

Lancereaux,  E.,  De  la  thrombose  et  de  I'embolie  cerebrales 
considerees  principalement  dans  leurs  rapports  avec  le  ramoUisse- 
ment  du  cerveau.  Paris,  1863. — Gelpke,  Ottomar,  Vergleichende 
Zusammenstellung  der  Symptome  von  Hirnapoplexie  und  Embo- 
lie  der  Hirnavterien.  Archiv  der  Heilkunde,  1875. — Meissner, 
Bericlite  iiber  Embolien  und  Thrombosen.  Schmidfs  Jahrb.,  109, 
117,  131. 

The  cerebral  arteries  may  be  suddenly  plugged  by 
the  lodgment  of  a  portion  of  a  clot  or  other  foreign 
body  brought  from  a  distance,  an  embolus,  or  gradu- 
ally by  the  growth  of  a  tumor,  by  the  thickening  of  the 
walls  of  the  artery,  or  by  the  coagulation  of  the  blood 
at  the  point  where  the  obstruction  occurs.  The  sudden 
stopping  of  an  artery  by  a  clot  brought  from  a  distance 
is  called  embolism  ;  the  plugging  by  a  clot  formed  on 
the  spot  is  called  thrombosis. 

EMBOLISM. 

Etiology. — The  emboli  may  arise  in  the  pulmonary 
veins,  or  the  left  side  of  the  heart,  or  in-  any  of  the  ves- 
sels between  the  heart  and  the  point  where  they  lodge. 
Much  the  more  frequently  they  arise  in  the  heart  as 
the  products  of  acute  or  chronic  endocarditis.  Warty 
growths  form  on  the  valves,  are  torn  off  and  carried 
into  the  circulation,  or  a  blood-clot  forms  in  the  heart 
and  portions  are  broken  off.  Aneurisms  of  the  aorta 
are  sometimes  the  source  whence  the  fragments  of  clot 


108  DISEASES  OF  THE  BRAIN. 

arise.  Disease  of  the  lungs,  as  pneumonia  or  phthisis, 
cancer  or  embolism,  or  thrombosis  of  the  pulmonary- 
vessels,  may  serve  as  the  point  of  origin  of  an  embolus 
which  may  be  carried  by  the  pulmonary  vein  to  the 
heart,  and  thence  to  the  brain.  Any  diseases,  then, 
which  may  give  rise  to  endocarditis  or  the  above  pul- 
monary affections  are  remote  causes  of  embolism. 

Pathological  Anatomy. — It  is  not  necessary  to 
describe  the  changes  which  the  embolus  undergoes, 
except  to  say  that  in  rare  cases  it  is  broken  down  and 
absorbed. 

Immediately  after  the  occlusion  of  an  artery  the 
blood  from  the  veins  flows  back  into  the  distal  branches 
of  the  obstructed  artery,  and  there  is  more  or  less  sta- 
sis. In  the  brain  it  is  very  rare  that  the  anastomoses 
are  sufiicient  to  maintain  an  active  circulation,  hence 
the  region  which  depends  upon  these  branches  for  its 
nutrition  suffers  from  lack  of  healthy  blood  ;  the  walls 
of  the  vessels  also  suffer  and  allow  the  blood  to  escape. 
The  cerebral  tissue  is  infiltrated  with  serum,  the  blood 
undergoes  change,  and  its  coloring-matter  is  diffused 
through  the  part,  and  gives  a  red  or  yellowish  tint  to 
the  broken-down  nervous  tissues. 

The  nervous  elements,  being  deprived  of  healthy 
blood,  lose  their  vitality,  soften,  undergo  fatty  degen- 
eration, and  are  reduced  to  a  semi-fluid  pulp.  If  the 
region  affected  is  small,  this  may  be  absorbed,  a  cica- 
trix is  formed,  and  the  spot  of  softening  may  finally 
disappear,  but  more  frequently  a  cyst  remains  filled 
with  serum  and  crossed  by  bands  of  connective  tissue. 

The  softening  does  not  show  itself  immediately  ;  it 
is  percei)tible  only  thirty-six  to  forty-eight  hours  after 
the  occlusion  of  an  artery. 

Owing  to  the  direction  in  which  the  different  arteries 
are  given  off  from  their  main  trunks,  emboli  are  much 
the  more  frequently  carried  into  the  left  carotid,  and 
are  generally  lodged  in  the  middle  cerebral  artery  or 
one  of  its  branches.     Duret  has  described  the  distribu- 


EMBOLISM.  109 

tion  of  softening  wliicli  belong  to'  the  various  branches 
of  the  cerebral  arteries. 

Symptoms. — Generally  without  warning,  the  patient 
is  attacked  with  loss  of  consciousness  and  entire  loss  of 
power.  There  may  be,  for  a  few  minutes,  headache  or 
vertigo,  but  the  attack  is  usually  sudden  and  complete. 
The  loss  of  consciousness  is  of  less  duration  than  in 
haemorrhage,  and  may  be  only  momentary.  It  is  fre- 
quently accompanied  with  general  epileptiform  con- 
vulsions. Vomiting  and  delirium  are  sometimes  pres- 
ent. Occasionally  paralysis  is  the  first  symptom. 
Consciousness  is  not  always  lost ;  there  may  be  merely 
confusion  of  thought. 

After  recovery  of  consciousness  and  voluntary  power 
it  will  be  found  that  the  patient  has  paralysis  of  one 
side.  Usually  the  face  and  limbs  of  the  side  opposite 
the  lesion  are  affected,  and  as  the  left  middle  cerebral 
artery  is  much  the  more  frequently  the-  seat  of  embo- 
lism, the  right  side  is  usually  the  one  affected. 

The  temperature  is  slightly  lowered  immediately 
after  an  attack,  but  quickly  rises,  and,  if  the  case 
proves  fatal  within  three  or  four  days,  the  rise  of  tem- 
perature is  almost  unbroken.  If  the  patient  lives  from 
five  to  fifteen  days,  the  temperature  is  irregular.  If 
the  attack  is  not  fatal,  the  temperature  falls  to  very 
nearly  or  quite  to  the  normal  after  three  or  four  days. 

After  the  earlier  stage  of  the  disease  the  symptoms 
are  essentially  the  same  as  in  haemorrhage.  Contrac- 
tion of  the  limbs  is  seen  less  frequently  than  after 
haemorrhage,  yet  is  essentially  the  same  when  it  oc- 
curs. The  intellectual  disturbance  is  rather  less 
marked. 

Disturbance  of  the  faculty  of  speech  is  not  uncom-- 
mon  in  embolism,  and  when  the  right  side  is  paralyzed 
there  is  almost  always  aphasia. 

Occasionally  the  aphasia  is  the  only  symptom  pres- 
ent ;  there  is  no  loss  of  consciousness,  nor  paralysis. 
Some  of  these  cases  are  due  to  embolism  of  small  ar- 


110  DISEASES  OF  THE  BRAIK 

teries,  some  are  due  to  disturbance  of  circulation  de- 
pending upon  other  causes. 

The  embolus  may  lodge  in  an  artery,  stop  the  blood- 
current  for  a  few  minutes,  and  then,  by  a  change  of  its 
position,  the  blood  may  be  able  to  pass  it  in  sufficient 
quantity  to  restore  the  nutrition  of  the  brain.  If  the 
embolus  is  then  broken  up  and  absorbed,  there  may  be 
no  further  trouble  ;  or  if  it  adheres  firmly  to  the  wall 
of  the  vessel,  there  may  be  no  further  trouble.  If, 
however,  its  position  is  again  changed,  it  may  plug  the 
vessel  finally,  and  then  the  symptoms  become  perma- 
nent. 

When  other  than  the  middle  cerebral  artery  is 
plugged  by  an  embolus,  the  symptoms  will  vary  ac- 
cording to  the  portion  of  the  brain  affected, 

DiAGisrosis, — The  diagnosis  is  almost  exclusively  be- 
tween haemorrhage  and  embolism.  The  question  as  to 
the  diagnosis. of  thrombosis  is  reserved  till  the  latter 
affection  has  been  considered. 

It  is  frequently  impossible  to  be  certain  whether 
there  has  been  embolism  or  haemorrhage ;  but,  by  a 
careful  consideration  of  all  the  symi)toms  and  other 
circumstances,  it  will  generally  be  possible  to  form  a 
satisfactory  diagnosis. 

Gelpke  has  given  a  valuable  review  of  the  diagnostic 
points  between  apoplexy  and  embolism.  The  first  is 
age  ;  apoplexy  is  by  far  the  more  frequent  after  fifty — 
embolism  before  fifty.  More  than  sixty  per  cent  (near- 
ly or  quite  seventy  per  cent)  of  the  cases  of  apoplexy 
occur  after  fifty  ;  more  than  sixty  per  cent  of  the  cases 
of  embolism  occur  before  fifty. 

In  haemorrhage  there  is  disease  of  arteries  ;  so  this 
is  found  most  frequently  in  connection  with  Bright's 
disease  or  where  there  are  atheromatous  changes. 
Embolism  occurs  most  where  there  is  cardiac  valv- 
ular disease.  In  haemorrhage  there  may  be  premoni- 
tory symptoms ;  in  embolism  the  attack  occurs  gen- 
erally without  warning.     When  there  seem  to  be  pre- 


EMBOLISM.  Ill 

monitory  symptoms,  they  are  rather  due  to  independent 
attacks. 

The  symptoms  which  are  found  during  and  immedi- 
ately after  the  attack  may  be  very  much  alike,  yet 
there  are  slight  differences  which  may  aid  in  diagnosis. 
Both  embolism  and  haemorrhage  are  frequently  accom- 
panied with  hemiplegia ;  but  in  embolism  it  is  almost 
always  on  the  right  side;  in  haemorrhage  on  either 
side  :  so  left  hemiplegia  would  rather  point  to  haemor- 
rhage ;  right  hemiplegia  not  necessarily  to  embolism. 
Epileptic  attacks  at  the  time  of  seizure  rather  indi- 
cate embolism.  The  muscular  paralysis  is  greater 
in  embolism  than  in  hsemori'hage.  Aphasia,  agraphia, 
and  amimia  depend  upon  changes  in  or  near  the 
island  of  Reil,  and  are  the  more  frequent  in  embo- 
lism. Ataxic  loss  of  speech  depends  upon  lesion  of 
the  corpus  striatum,  and  is  the  more  common  in  haem- 
orrhage. In  embolism  the  symptoms  of  cerebral  press- 
ure are  wanting,  as  diminished  frequency  of  pulse, 
stertorous  respiration,  vomiting,  contracted  pupil,  and 
strabismus. 

After  the  attack  the  mental  powers  are  more  likely 
to  be  affected  in  haemorrhage,  especially  the  emotional 
faculties.  There  is  also  more  likely  to  be  reaction ;  and 
a  return  of  function,  if  it  occurs,  is  slower  in  haemor- 
rhage. 

The  discovery  of  an  embolism  in  other  arteries,  as 
radial,  femoral,  etc.,  would  aid  in  establishing  a  diag- 
nosis. 

The  temperature  may  also  assist.  In  embolism,  dur- 
ing the  first  few  hours,  the  initial  depression  of  tem- 
perature below  normal  is  wanting  or  very  slight ;  in 
haemorrhage  it  is  much  more  marked.  In  embolism, 
after  a  temporary  rise,  the  temperature  returns  to  the 
normal  with  irregular  exacerbations  or  evening  eleva- 
tions ;  in  haemorrhage  it  returns  less  quickly  to  the 
normal  unless  a  second  haemorrhage  occurs.  After  the 
stationary  period  the  rise  of  temperature  is  slower  in 


112  DISEASES  OF  TEE  BRAIK 

embolism,  and  generally  does  not  attain  so  Mgb.  a 
figure  as  in  hsemorrhage. 

Exceptional  cases  of  embolism  occur  where  the  vari- 
ation of  temperature  more  nearly  resembles  that  found 
in  hsemorrhage. 

If  there  is  complete  recovery  within  a  few  days  after 
an  attack  of  complete  hemij)legia,  there  probably  was 
not  haemorrhage. 

Peognosis. — "At  the  outset  of  and  during  the  pri- 
mary attack,  no  prognosis  can  be  given  as  to  the  prob- 
able course  of  the  case,  except  that  its  severity  is  likely 
to  be  proportionate  to  the  extension  and  severity  of  the 
primary  symptoms.  If  the  paralytic  symptoms  disap- 
pear after  a  brief  period,  there  will  be  no  reason  to  fear 
the  presence  of  serious  structural  disease,  but  the  chance 
of  future  attacks  can  not  be  excluded."  ("Ziems. 
Cyclop.") 

Severe  cases  are  more  serious  than  severe  cases  of 
haemorrhage,  and  more  likely  to  prove  fatal. 

When  the  vertebral  or  basilar  artery  is  plugged,  the 
prognosis  must  necessarily  be  very  unfavorable. 

Treatment. — Unless  the  patient  is  very  feeble  and 
requires  slight  stimulation,  the  less  done  during  the 
first  few  days  the  better.  Blood-letting  and  depressing 
measures  are  decidedly  contra-indicated.  If  there  arise 
indications  of  cerebral  irritation  from  collateral  hyper- 
aemia,  the  bowels  should  be  freely  acted  upon  and  the 
head  kept  cool. 

The  subsequent  treatment  may  be  the  same  as  in 
cerebral  haemorrhage. 

THROMBOSIS   OF   CEREBRAL   ARTEEIES. 

Etiology. — The  causes  of  thrombosis  of  cerebral 
arteries  are  to  be  found  either  in  the  vessels  themselves, 
in  the  composition  of  the  blood,  or  in  the  diminished 
action  of  the  heart.  The  walls  of  the  vessels  may  be- 
come roughened  from  disease,  as  in  arteritis  obliterans, 
whether  syphilitic  or  not,  and  also  in  case  of  atheroma. 


THROMBOSIS  OF  CEREBRAL  ARTERIES.  113 

especially  if  the  inner  epithelial  layer  is  broken ;  the 
vessel  may  be  contracted  through  a  small  extent  of  its 
length,  and  thus  the  blood-current  be  retarded.  The 
disease  of  the  walls  of  the  vessels  as  found  in  old  age 
interferes  with  their  normal  elasticity,  and  so  favors 
retardation  and  coagulation  of  the  blood.  Disease  or 
weakness  of  the  heart  may  also  cause  the  blood  to  flow 
less  rapidly,  and  so  favor  the  formation  of  a  thrombus  ; 
or  the  blood  may  coagulate  more  readily  than  usual,  as 
in  certain  febrile  diseases.  Disease  of  arteries  and  fee- 
bleness of  heart's  action  are  found  combined  in  old  age ; 
consequently  thrombosis  is  most  common  in  advanced 
life ;  very  few  cases  occur  below  forty  years  of  age ; 
most  patients  are  over  sixty. 

Pathological  Aistatomy. — When  the  thrombus 
fills  an  artery  whose  branches  are  not  connected  by  an- 
astomoses with  other  arterial  supply,  the  brain,  deprived 
of  blood,  must  necessarily  undergo  the  same  degenera- 
tion as  is  found  in  embolism.  Often  the  smaller  end 
arteries  are  stopped  up,  and  then  small  spots  of  soften- 
ing will  be  found  throughout  the  brain ;  this  is  most 
commonly  seen  in  the  white  substance.  The  cavities 
thus  formed  may  vary  in  size  from  a  sixteenth  of  an 
inch  in  diameter  to  an  inch  or  more ;  if  numerous,  they 
average  an  eighth  to  a  quarter  of  an  inch ;  they  are 
crossed  by  bands  of  connective  tissue  containing  blood- 
vessels ;  there  may  be  a  new  growth  of  vessels  if  inflam- 
mation has  set  in.  The  walls  of  these  cavities  usually 
contain  granular  corpuscles.  If  recent,  the  nerve-fibers 
around  the  border  of  the  cavity  may  show  enlargement 
of  axis- cylinders  and  other  inflammatory  changes. 

Sometimes,  instead  of  a  cavity,  cicatricial  tissue 
forms  and  a  hard  nodule  is  left. 

Symptoms. — As  the  arteries  are  usually  closed  grad- 
ually, there  is  a  less  sudden  onset  of  the  symptoms  than 
is  found  in  embolism.  For  a  variable  length  of  time 
the  patient  has  had  more  or  less  discomfort  in  the  head 
— pain  or  dizziness — ^memory  may  be  less  strong,  the 


114  DISEASES  OF  THE  BRAIK 

patient  may  show  signs  of  mental  disturbance  or  tem- 
porary loss  of  consciousness,  which  are  referred  to  old 
age,  or  there  may  be  actual  insanity ;  sometimes  tem- 
porary loss  of  power  or  abnormal  sensations  in  the 
limbs,  which  soon  pass  away,  but  again  appear,  show 
that  there  is  serious  disturbance  of  the  cerebral  circula- 
tion. If  the  region  of  the  pons  and  cerebral  peduncles 
are  affected,  individual  cranial  nerves  may  be  more  or 
less  paralyzed.  There  may  be  a  numbness  and  tingling 
in  the  limbs  on  one  or  both  sides,  or  a  slowly  increas- 
ing paralysis  may  be  the  result  of  gradual  loss  of 
power  in  the  motor  tracts. 

After  thesfe  undefined,  perhaps  doubtful  and  confus- 
ing, symptoms  have  continued,  it  may  be  for  months, 
there  may  occur  an  apoplectic  attack  ;  the  vessel  which 
had  been  only  partially  obliterated  is  suddenly  entirely 
plugged  ;  then  the  symptoms  of  embolism  follow. 

Diagnosis. — Thrombosis  and  embolism  differ  in  the 
above  premonitory  stage,  which  perhaps  may  be  de- 
scribed more  properly  as  the  gradual  development  of 
the  symptoms. 

It  may  be  almost  impossible  to  decide  whether  there 
is  a  thrombus  or  a  haemorrhage  when  the  artery  is  final- 
ly plugged  suddenly.  A  number  of  independent  attacks 
of  paralysis,  of  unconsciousness,  or  of  dizziness,  from 
which  the  patient  soon  recovers,  followed  by  the  finally 
permanent  attack;  the  advance  of  the  symptoms  by 
stages,  as  it  were,  with  intervals  when  there  was  no  ad- 
vance— would  point  to  a  thrombus  rather  than  a  haemor- 
rhage. A  preceding  or  accompanying  acute  disease,  as 
pneumonia,  or  a  great  general  feebleness,  should  cause 
a  suspicion  of  thrombosis.  Age,  disease  of  arteries 
and  of  kidneys,  would  be  as  significant  of  one  as  the 
other. 

After  the  apoplectic  attack  the  diagnosis  of  thrombus 
would  be  made  from  the  same  peculiarities  as  are  found 
in  embolism. 

When  there  are  several  attacks  of  unconsciousness, 


THROMBOSIS  OF  CEREBRAL  ARTERIES.  115 

or  of  paralysis,  or  of  dizziness,  there  may  be  a  question 
as  to  wliether  the  patient  is  suffering  from  epilepsy.  It 
should  be  kept  in  mind  that  epilepsy  rarely  originates 
in  old  age ;  a  careful  study  of  the  phenomena  attending 
the  attack  will  show  a  lack  of  resemblance  with  epilep- 
sy ;  bromide  of  potassium  is  more  likely  to  aggravate 
the  symptoms  in  thrombosis,  but  relieves  them  in  epi- 
lepsy. 

The  diagnosis  of  locality  must  be  made  from  com- 
parison of  symptoms  with  facts  which  have  already 
been  given,  only  remembering  that  the  symptoms  due 
to  pressure  would  be  absent. 

Peogxosis. — The  physician  must  judge  of  the  dan- 
ger to  life  by  the  course  and  severity  of  the  symptoms. 
The  more  extended  the  signs  of  disturbance,  the  longer 
the  unconsciousness  continues,  the  more  certain  the  le- 
sion can  be  located  in  the  mesencephalon,  the  more 
serious  must  be  the  prognosis. 

Teeatment. — When  a  diagnosis  of  thrombosis  can 
be  made,  the  treatment  should  be  tonic  and  mildly 
stimulating  ;  when  it  is  impossible  to  certainly  exclude 
haemorrhage,  it  is  not  desirable  to  give  stimulants  free- 
ly ;  and  in  very  doubtful  cases  it  may  be  better  to  do 
nothing  more  than  to  put  the  patient  in  as  favorable 
hygienic  conditions  as  possible,  insure  quiet,  rest,  and 
absence  of  excitement.  If  the  patient  is  young,  and 
has  had  syphilis,  a  course  of  iodide  and  mercury  would 
certainly  be  appropriate. 

After  an  apoplectic  attack  the  treatment  would  be 
the  same  as  under  similar  circumstances  arising  from 
other  causes. 


CHAPTEK  VII. 

TUMOES   OF   THE  BEAIIf. 

Ladame,  Paul,  Symptomatologie  und  Diagnostik  der  Hirnge- 
schwiilste.  1865. — Macabian,  Jean  Firmin,  Quelques  considera- 
tions sur  les  tumeurs  du  cervelet.  Paris,  1869. — Bramwell,  By- 
ron, Clinical  Lectures  on  Intra-cranial  Tumors.  Edinburgh  Med. 
Jour.,  1881. — NoTHNAGEL,  H.,  Topische  Diagnostik  der  Gehirn- 
krankheiten.  Berlin,  1879. — Bernhardt,  M.,  Beitrage  zur  Symp- 
tomatologie und  Diagnostik  der  Hirngeschwiilste.  Berlin,  1881. 
— Klebs,  E.,  Beitrage  zur  Geschwiilstlehre  —  Hirngeschwiilste. 
Prag.  Vierteljschr.,  cxxxiii. — Jackson,  J.  H.,  Diagnosis  of  Tumor 
of  Brain.    Med.  Times  and  Gaz.,  August  9,  1873. 

Pathological  Aisr atomy.  —  Many  of  the  tumors 
whicli  are  found  within  the  skull  are  not  properly  tu- 
mors of  the  brain — that  is,  do  not  take  their  rise  from 
the  cerebral  tissue,  but  arise  from  the  meninges  or  the 
blood-vessels ;  some  arise  from  the  bones  of  the  skull. 
As  all  these  are  revealed  to  us  by  the  symptoms  pro- 
duced by  their  influence  upon  the  brain,  it  is  proper 
and  most  convenient  to  include  all  under  the  term  "tu- 
mors of  the  brain." 

It  is  unnecessary  to  give  details  of  the  histology  of 
the  different  kinds  of  tumors  which  may  be  found  in 
the  brain  or  connected  with  its  envelopes.  Tubercle, 
cancer,  gummata,  sarcoma,  osseous  growths,  myxoma, 
and  lipoma  do  not  differ  essentially  from  the  same 
growths  found  elsewhere.  Glioma,  psammoma,  and 
cholesteatomata  are  among  the  tumors  which  more 
peculiarly  belong  to  the  brain.  The  first,  glioma,  is 
simply  a  development  of  the  normal  neuroglia  with 
sometimes  the  admixture  of  more  or  less  fibrous  tissue. 


TUMORS  OF  TEE  BRAIK  II7 

They  vary  in  consistency  according  as  cells  or  fibrous 
tissue  predominate. 

Psammoma  consist  in  the  formation  of  granules  of 
calcareous  substance  infiltrated  into  the  cellular  tissue. 
There  may  be  also  hyperplasia  of  the  pineal  gland  or 
of  the  pituitary  gland. 

Etiology. — Certain  tumors,  as  tubercle,  cancer,  or 
syphilitic  gummata,  must  be  referred  to  a  constitutional 
diathesis.  Blows  and  falls  upon  the  head  are  often  the 
direct  cause  of  the  development  of  abnormal  growths. 
The  cause  of  a  large  number  of  tumors  can  not  be  cer- 
tainly discovered. 

Symptoms. — There  are  certain  symptoms  which  may 
be  called  general,  or  common,  which  are  found  in  almost 
every  case  of  intercranial  tumor  without  reference  to  its 
locality  ;  other  symptoms  depend  upon  the  situation  of 
the  tumor  and  aid  in  locating  it.  The  latter  symptoms 
are  important  as  well  in  assisting  to  form  a  diagnosis  of 
the  presence  of  a  tumor,  the  common  or  general  symp- 
toms oftentimes  not  being  definite  enough  for  that  pur- 
pose. 

Sometimes  a  tumor  gives  rise  to  so  few  symptoms, 
or  they  are  so  slight,  that  no  notice  is  taken  of  them, 
or  there  may  be  no  symptoms.  This  is  more  likely  to 
occur  where  the  tumor  is  quite  small,  where  it  is  situ- 
ated in  certain  parts  (anterior  or  posterior)  of  the  white 
substance,  and  where  it  is  very  slow  in  growth. 

The  symptoms  depend  upon  the  immediate  effect  of 
the  tumor  upon  the  nervous  structures,  destruction  or 
irritation ;  upon  its  effect  at  a  distance,  irritation  and 
pressure  ;  and  upon  the  inflammatory  or  other  changes 
which  it  excites  in  the  cerebral  substance,  more  espe- 
cially in  its  vicinity. 

The  general  symptoms  are,  in  most  instances,  due  to 
the  remoter  effects  or  to  the  less  direct  changes  excited 
by  the  new  growth.  The  most  common  symptom  is 
headache ;  this  is  also  usually  one  of  the  first,  and  is 
characterized  by  its  persistency  and  the  severity  of  the 


118  DISEASES  OF  THE  BRAIN. 

paroxysms.  Remissions,  sometimes  even  intermissions, 
may  occur,  in  which  the  headache  is  replaced  by  a  feel- 
ing of  slight  discomfort  in  the  head.  In  some  cases  a 
slight  noise  or  the  least  motion  brings  on  an  attack. 
When  severe,  remedial  agents  have  no  power  to  allevi- 
ate the  pain.  The  more  rapid  the  growth  of  the  tumor, 
the  more  severe  and  persistent  is  the  headache. 

Dizziness,  or  vertigo,  is  a  frequent  symptom  in  the 
early  stages  of  the  disease.  Nausea  and  vomiting  are 
very  frequently  present,  and  may  be  very  obstinate. 
These  are  rather  the  more  frequent  when  the  posterior 
part  of  the  hemispheres  or  the  cerebellum  is  affected. 

Various  mental  disturbances  belong  among  the  ear- 
lier symptoms,  such  as  change  of  disposition,  a  pleasant, 
good-natured  patient  becoming  cross  and  irritable,  or 
one  who  has  been  careless  and  unconcerned  taking  upon 
himself  the  opposite  qualities ;  one  who  has  been  open 
and  frank  becoming  silent,  morose,  and  suspicious. 
Memory  fails,  power  of  mental  application  is  lost,  and 
business  cares  and  responsibilities  become  a  burden. 
I^one  of  these  changes  are  sufficient  to  rank  as  insanity  ; 
there  is  simply  slight  mental  disturbance,  which  may 
be  perceived  even  before  the  headache  shows  itself. 

When  all  these  symptoms  are  found  together,  per- 
sisting in  spite  of  treatment  or  only  partially  relieved 
thereby,  the  presence  of  cerebral  tumor  is  almost  cer- 
tain. The  diagnosis  is  yet  more  certain  when  any  of 
the  following  symptoms  are  also  present : 

There  may  be  a  general  failure  of  muscular  strength, 
no  definite  paralysis  of  any  set  of  muscles,  but  a  sim- 
ple and  increasing  enfeeblement.  When  the  cerebral 
disease  is  secondary  to  disease  elsewhere,  as  tubercular 
or  cancerous,  it  may  be  impossible  to  decide  how  much 
this  weakness  is  due  to  the  constitutional  state,  or  to 
the  local  disease  in  the  brain. 

Spasms  and  convulsions  are  sometimes  so  general  or 
indefinite  that  they  are  to  be  considered  as  general 
symptoms.      They  are,  however,  probably  dependent 


TUMORS  OF  TEE  BRAm.  119 

upon  an  irritation  of  the  cortical  gray  substance,  either 
direct  or  remote,  either  primary  or  reflex.  Spasms 
localized  in  one  or  a  few  groups  of  muscles  belong  to 
the  localizing  symptoms. 

There  is  rarely  pain  in  the  limbs,  but  various  abnor- 
mal sensations,  as  numbness,  formication,  pricking,  and 
tingling,  are  not  uncommon ;  sometimes  there  is  great 
diminution  of  ordinary  sensations. 

Disturbances  of  special  senses,  excepting  eyesight, 
are  not  common  ;  deafness  and  anosmia  are  rare  ;  taste  is 
lost  only  or  chiefly  when  the  mesencephalon  is  affected. 
Diplopia,  amblyopia,  amaurosis,  and  hemianopsia  are 
not  rare ;  they  belong  more  especially  to  localizing 
symptoms,  and  have  been  more  or  less  fully  considered 
already. 

Disturbance  of  speech,  rotatory  movements,  com- 
pelled movements  forward  or  backward,  conjugate  de- 
viation of  the  eyes  and  head,  also  belong  to  localizing 
symptoms,  and  have  been  considered  in  previous  pages. 

Optic  neuritis  is  very  frequently  one  of  the  second- 
ary or  remote  symptoms  of  cerebral  tumor,  and,  when 
present,  may  be  of  great  value  in  forming  a  diagnosis. 
In  every  case  of  cerebral  disturbance  the  ophthalmo- 
scope should  be  used,  whether  there  is  disturbance  of 
vision  or  not.  The  neuritis  may  exist  unsuspected  by 
the  patient. 

Other  signs  of  ill  health  may  be  present,  as  emaci- 
ation, anorexia,  pyrexia,  constipation,  retention  or  in- 
continence of  urine,  disturbance  of  circulation  or  of 
respiration. 

The'  symptoms  which  enable  one  to  localize  the  tu- 
mor have  been  mentioned  already ;  they  are  also  im- 
portant as  showing  the  presence  of  organic  change  in 
the  brain,  but  other  symptoms  indicate  the  nature  of 
that  change. 

The  temperature  of  the  body  is  not  very  often  raised, 
but  several  observations  of  the  temperature  of  the  head 
show  that  there  is  an  increase  of  surface-heat  on  the 


120  DISEASES  OF  THE  BRAIK 

side  where  the  tumor  is,  especially  immediately  over  it. 
This  branch  of  inquiry  has  not  been  pursued  far  enough 
as  yet  to  decide  whether  the  degree  of  elevation  has 
any  relation  to  the  nature  of  the  tumor  or  its  rapidity 
of  growth.  Great  care  is  necessary  in  taking  these  ob- 
servations to  guard  against  errors. 

The  course  of  the  disease  varies  greatly  according 
to  the  rate  of  increase  and  the  situation  of  the.  new 
growth.  It  is  hardly  necessary  to  say  that  a  rapidly 
growing  tumor  will  cause  many  more  severe  symptoms 
than  one  which  increases  in  size  more  slowly.  Inflam- 
mation or  congestion  around  a  tumor  may  give  rise  to  a 
sudden  outbreak  of  symptoms,  and  their  rapid  increase 
in  severity.  This  may  subside,  and  then  a  remission 
would  succeed. 

As  a  rule,  with  occasional  remissions,  or  even  inter- 
missions, in  the  symptoms,  there  is  a  steady  advance  ; 
the  headache  may  at  length  diminish  in  intensity,  per- 
haps because  of  destruction  of  nerve-fibers,  the  con- 
vulsions may  cease  because  the  motor  areas  are  de- 
stroyed, but  with  the  apparent  improvement  the  mental 
powers  wiU  be  found  to  have  diminished,  the  paralysis 
to  have  increased,  the  patient  is  more  helpless ;  while 
suffering  less,  he  has  evidently  lost  ground. 

At  length  there  is  complete  hemiplegia,  or  possibly 
paralysis  of  the  entire  body,  the  bladder  and  rectum 
are  affected  as  in  other  cases  of  hemiplegia,  and  bed- 
sores form  ;  it  becomes  constantly  more  difficult  to  give 
the  proper  nourishment,  and  the  patient  dies  exhausted. 

Many  times,  however,  the  fatal  termination  is  more 
speedily  reached,  the  respiration  or  heart's  action  is 
interfered  with,  or  pulmonary  complications  set  in, 
and  the  patient  soon  dies. 

The  duration  is  very  variable  ;  cancer,  tubercle,  and 
syphilitic  growths  are  rapid  in  their  course ;  glioma 
may  slowly  advance  for  years,  with  many  intermis- 
sions. 

There  are  many  questions  which  it  would  be  inter- 


TUMORS  OF  THE  JSRAIX  121 

esting  to  consider,  but  the  object  is  simply  to  lead  to  a 
correct  diagnosis,  and  indicate  the  most  rational  treat- 
ment. 

Diagnosis. — The  diagnosis  of  tumors  of  the  brain 
from  other  cerebral  affections  is  by  no  means  always 
easy.  Tubercular  meningitis  may  sometimes  closely 
resemble  tumor.  It  is  more  common  in  children  than 
adults,  while  tumors  are  more  frequent  in  adults. 

Chronic  thickening  of  the  memhranes,  especially  if 
occurring  at  the  base,  so  as  to  involve  the  cranial  nerves, 
may  give  rise  to  exactly  the  same  symptoms  as  a  tu- 
mor. Such  thickening  is  more  frequently  seen  as  the 
effect  of  a  syphilitic  taint. 

Abscess  of  the  brain  is  usually  accompanied  with  less 
headache,  is  less  likely  to  have  ocular  symptoms,  to 
cause  vomiting  and  vertigo,  and  is  more  frequently  the 
result  of  an  affection  of  the  ears. 

Apoplexy  and  embolism  may  generally  be  distin- 
guished from  tumor  by  the  suddenness  with  which  the 
symptoms  occur,  and  the  peculiarities  of  the  first  at- 
tack. Nevertheless,  in  rare  cases,  tumors  have  re- 
mained comparatively  latent  for  an  indefinite  period 
of  time,  and  then  manifested  their  presence  by  an  at- 
tack closely  resembling  apoplexy.  A  careful  study  of 
the  symptoms  attending  the  onset,  and  the  previous 
state  of  the  patient's  health,  especially  whether  any  of 
the  general  symptoms  indicating  tumor  existed,  also  an 
examination  of  the  heart  and  kidneys,  would  assist  ma- 
terially to  a  correct  diagnosis. 

An  obstinate  and  persistent  headache,  such  as  some- 
times occurs  at  puberty,  may  give  rise  to  anxious  fore- 
bodings, lest  it  should  be  significant  of  serious  brain 
trouble ;  much  more  would  such  anxiety  arise  if  the 
headache  were  attended  with  attacks  of  vomiting.  A 
careful  study  of  the  whole  history  of  the  case,  and  a 
careful  examination  of  the  patient,  will  aid  more  than 
anything  in  forming  a  diagnosis  ;  but  it  may  be  neces- 
sary to  wait  for  time  to  settle  the  question. 


122  DISEASES  OF  TEE  BRAIK 

PROGisrosis. — The  result  is  almost  invariably  fatal, 
the  patient  being  finally  worn  out  by  bed-sores,  or  de- 
bilitated by  insufficient  nourishment  from  the  difficulty 
of  swallowing  or  the  continuous  vomiting.  Sometimes 
the  fatal  termination  occurs  during  an  epileptic  attack, 
or  in  an  attack  of  apoplexy.  It  is  almost  impossible 
to  Judge  with  any  degree  of  certainty  in  regard  to  the 
duration  of  life. 

Possibly,  if  the  growth  is  syphilitic  and  has  not  at- 
tained too  large  a  size,  there  may  be  recovery ;  though 
recovery  itself  might  throw  some  doubt  upon  the  cor- 
rectness of  the  diagnosis. 

Treatment. — The  treatment  of  cerebral  tumors  may 
be  included  under  two  heads — treatment  designed  to 
cure  the  patient,  and  that  intended  to  relieve  certain 
symptoms.  Where  there  has  been  a  previous  syphi- 
litic infection,  it  is  advisable  to  pursue  an  active  course 
of  antisyphilitic  treatment — iodide  of  potassium  with- 
out hesitation  in  sufficient  doses  to  produce  a  marked 
effect  within  a  comparatively  short  time,  and  mercury. 
Even  where  syphilis  is  not  proved,  a  course  of  iodide 
of  potassium  may  be  of  great  benefit. 

Counter-irritation  to  the  head  and  neck  has  been 
recommended.  It  is  extremely  doubtful  if  the  growth 
of  a  tumor  is  influenced  thereby,  though  some  of  the 
unpleasant  symptoms  may  be  mitigated. 

To  fulfill  the  second  indication — ^if  convulsions  of  an 
epileptiform  character  are  frequent — one  of  the  bro- 
mides in  large  doses  may  give  more  or  less  relief. 
As  headache  is  one  of  the  most  distressing  symptoms, 
patients  are  imperious  in  their  demands  to  be  relieved 
therefrom  ;  if  apparently  not  very  severe,  milder  meas- 
ures may  first  be  tried,  as  counter-irritation  to  the  neck, 
bromide  of  potassium,  cannabis  Indica,  caffein.  If  the 
pain  is  severe,  probably  nothing  will  relieve  it  except 
one  of  the  preparations  of  opium.  There  should  be 
no  hesitation  in  using  this  drug  in  such  doses  as  to  give 
relief.     Often  a  comparatively  small  dose  will  accom- 


TUMORS  OF  THE  BRAIK  123 

plish  the  purpose ;  it  is  well  occasionally  to  intermit 
its  use  to  learn  whether  the  headache  may  not  have 
ceased  ;  at  such  times  a  weak  solution  of  quinine  may 
very  conveniently  take  the  place  of  morphine  by  the 
mouth,  or  water  may  be  used  for  subcutaneous  injec- 
tion. 

The  vomiting  which  accompanies  cerebral  tumor  is 
often  very  obstinate  and  intractable.  It  should  be 
treated  according  to  the  condition  of  the  patient. 
Counter-irritation  to  the  head  and  neck  or  over  the 
stomach  should  not  be  omitted  when  other  means  fail. 
Ice  to  the  head  and  neck  may  be  useful.  If  other 
means  do  not  succeed,  morphia  may  control  it. 

Of  course,  the  conditions  of  the  patient,  which  re- 
quire special  treatment,  as  cystitis,  bed-sores,  etc., 
should  receive  the  necessary  care. 


CHAPTER  yill. 

CEREBRAL    ABSCESS. 

KoHLER,  A.,  Ein  Beitrag  zur  Lehre  von  Gehirnabscess. 
SchmidVs  Jahrb.,  183,  1879. — Meyer,  R,  Zur  Pathologie  des 
Hirnabscesses.  Zurich,  1867. — N aether,  R.,  Die  metastatischen 
Hirnabscesse  nach  primaren  Lungenberden.  Deut.  Arch.  M.  Med., 
xxxiv,  1883. — Thompson,  H.,  Case  of  Otitis,  Cerebral  Abscess,  etc. 
Med.  Times  and  Gaz.,  March  29,  1878.— Fenger,  Christian,  On 
Opening  and  Drainage  of  Abscess  Cavities  in  the  Brain.  Am. 
Jour,  of  the  Med.  Sci.,  July,  1884. 

ABSCESS  OF  THE  BRAIN. 

Etiology.  — The  causes  of  cerebral  abscess  are  almost 
always  evident.  One  of  the  most  common,  perhaps  the 
most  common  cause,  is  inflammation  of  the  ear.  When 
the  otitis  affects  the  bone,  there  is  always  danger  that 
the  disease  may  extend  to  the  brain  ;  either  the  bone  is 
perforated,  and  so  the  dura  and  pia  mater  exposed  to 
direct  irritation,  or,  as  is  more  frequent,  the  inflamma- 
tion is  transmitted  through  the  foramina  or  veins.  In 
all  cases  of  otorrhoea  in  children,  the  danger  of  this 
complication  should  be  kept  in  mind. 

Injuries  to  the  head,  whether  attended  with  fract- 
ure of  the  bone  or  not,  are  frequent  causes  of  cerebral 
abscess. 

Disease  of  the  bone,  caries,  from  whatever  cause, 
may  give  rise  to  abscess.  An  abscess  may  form  about 
a  haemorrhage,  or  the  infarctus  due  to  an  embolism  or 
thrombus. 

Pyaemia  may  be  a  cause  ;  erysipelas  and  acute  dis- 
eases seem  sometimes  to  give  rise  to  cerebral  abscess. 


ABSCESS  OF  TEE  BRAIK  125 

Pathological  Anatomy. — The  division  has  been 
made  of  red  and  yellow  inflammation :  the  distinction 
depends  upon  the  relative  amount  of  blood  or  pus  con- 
tained in  the  diseased  tissue.  Abscesses  may  be  en- 
cysted, i.  e.,  surrounded  by  a  close,  firm  layer  of  new- 
formed  tissue  ;  or  they  may  have  no  containing  wall, 
the  pus,  mixed  with  debris  of  the  cerebral  substance, 
being  in  direct  contact  with  the  softened,  partly  broken- 
down  tissues. 

The  abscess  may  vary  in  size  from  very  small  to  in- 
clude nearly  a  whole  hemisphere. 

The  histological  changes  which  the  tissues  pass 
through  consist  in  a  cloudy  swelling  of  the  elements, 
a  gradual  breaking  up  into  granular  debris  and  trans- 
formation into  granular  corpuscles,  and  increase  of 
connective-tissue  fibers  and  cells  around  the  focus, 
when  a  capsule  is  formed. 

The  nervous  elements  themselves  are  destroyed  by 
fatty  or  granular  degeneration,  sometimes  preceded  by 
swelling,  or  hypertrophy  of  axis-cylinders  and  nerve- 
cells. 

Around  the  abscess  there  may  be  very  great  oedema 
of  the  cerebral  tissue,  and  sometimes  congestion,  some- 
times an  anaemic  condition. 

Symptoms. — The  symptoms  are  quite  similar  to 
those  attending  tumor  of  the  brain.  Headache  is  one 
of  the  most  common.  This  is  severe,  and  generally 
continuous.  If  not  intense,  there  is  at  least  a  feeling 
of  discomfort,  of  pressure,  of  lightness,  or  dizziness. 

Mental  confusion,  disturbed  memory,  sometimes 
delirium,  show  how  seriously  the  higher  intellectual 
faculties  are  implicated. 

Nausea  and  vomiting  may  be  among  the  earlier 
symptoms,  and,  if  very  persistent  soon  after  an  injury 
to  the  head,  or  if  they  set  in  during  an  attack  of  otor- 
rhoea,  should  give  reason  to  suspect  abscess. 

Paralysis  and  disturbance  of  sensation  other  than 
headache  are  not  very  common ;  sometimes  the  motor 


126  DISEASES  OF  THE  BRAIR. 

centers,  or  motor  tracts,  are  affected,  and  then  local 
paralysis  or  henaiplegia  may  be  noticed. 

Convulsions  are  rather  common ;  they  may  be  local 
only ;  or,  as  is  more  frequent,  beginning  as  local,  they 
become  general ;  they  may,  from  their  commencement, 
be  clearly  epileptic  in  character.  The  increased  irrita- 
bility of  the  motor  centers  caused  by  the  inflammation 
fully  explains  their  occurrence. 

When  pressure  increases,  there  may  be  the  corre- 
sponding symptoms — retarded  pulse,  stupor,  stertorous 
respiration,  etc. 

Sometimes  meningitis  is  one  of  the  results  of  the 
injury  or  disease  causing  the  abscess ;  then  the  symp- 
toms of  cerebral  meningitis  may  predominate. 

Either  the  abscess  runs  a  rapid  course,  terminating 
fatally  within  a  few  days  or  weeks,  or  a  period  of  re- 
mission may  set  in  ;  the  abscess  may  remain  latent  for 
an  indefinite  time.  When  thus  latent,  it  is  probably 
always  encysted.  During  this  time  of  remission  or 
latency,  some  of  the  symptoms  may  persist  in  a  dimin- 
ished degree  of  intensity.  In  other  cases  there  is  no 
acute  initial  stage  ;  the  abscess  from  the  beginning  runs 
a  chronic  or  concealed  course.  At  length  an  active  in- 
flammation starts  up  around  the  abscess,  and  all  the 
symptoms  are  aggravated,  the  patient  becomes  paralyzed 
and  comatose,  and  soon  dies  ;  or  the  oedema  around  the 
focus  of  disease  increases  suddenly  and  rapidly,  and 
so  the  patient  dies. 

The  abscess  may  rupture  into  the  lateral  ventricles, 
giving  rise  to  sudden  aggravation  of  the  symptoms ; 
general  convulsions  are  usually  excited ;  there  may  be 
loss  of  consciousness. 

Very  rarely  a  local  meningitis  is  excited,  the  mem- 
branes adhere,  the  bone  is  perforated,  and  the  abscess 
is  discharged  externally.  The  evacuation  may  be  fol- 
lowed by  recovery.  Occasionally  recovery  results  with- 
out discharge  of  the  contents. 

Diagnosis. — Cerebral  abscesses  have  many  symp- 


ABSCESS  OF  TEE  BEAIK  127 

toms  common  to  cerebral  tumors  :  headache,  vomiting, 
dizziness,  the  symptoms  of  pressure,  are  common  to 
both  affections. 

The  preceding  otorrhoea,  or  the  history  of  an  in- 
jury not  long  before  the  cerebral  symptoms  are  devel- 
oped, would  indicate  an  abscess.  If  a  tumor  follows 
an  injury,  a  much  longer  interval  must  elapse  before  it 
shows  its  presence.  Local  paralysis  and  hemiplegia 
are  more  common  with  tumors,  excepting  toward  the 
later  stages.  A  rapid  increase  in  severity  of  symptoms 
after  a  period  of  remission,  amounting  perhaps  almost 
to  intermission,  is  indicative  of  abscess.  Local  convul- 
sions, followed  sometimes  by  general  convulsions,  are 
met  in  tumors  of  the  cortex  ;  general  convulsions,  with- 
out preceding  local  spasms,  are  more  common  in  ab- 
scess. The  diagnosis  between  abscess  and  tumor  may, 
however,  frequently  be  impossible. 

Meningitis  is  accompanied  by  higher  fever,  by  more 
marked  cutaneous  hypersesthesia,  less  frequently  by 
convulsions.  Yet  the  diagnosis  may  be  very  difficult 
or  impossible,  especially  as  meningitis  may  be  pro- 
duced by  the  same  causes  as  abscess,  and  the  two  dis- 
eases may  co-exist,  one  as  the  cause  of  the  other,  or  both 
depending  upon  the  same  cause. 

The  diagnosis  of  locality  is  less  easy  than  in  other 
forms  of  cerebral  disease.  The  same  general  principles 
should  guide  in  a  decision,  but,  as  a  rule,  the  data  upon 
which  to  found  an  opinion  are  fewer  and  less  trust- 
worthy. After  an  injury  the  abscess  may  be  on  the 
opposite  side,  the  brain  having  suffered  there  by  eontre 
coup. 

Pkogt^osis. — Recovery  is  the  exception — so  rare  that 
little  account  need  be  taken  of  such  cases.  A  remis- 
sion may  excite  strong  hopes  of  cure,  but  there  is  the 
constant  danger  of  a  return  of  the  symptoms  in  a  more 
aggravated  form. 

Treatment. — After  an  encephalitis  has  gone  so  far 
as  to  give  rise  to  an  abscess,  medical  skill  is  compara- 


128  DISEASES  OF  THE  BRAIN. 

tively  powerless.  The  treatment  must  then  consist  in 
quiet,  rest,  and  avoidance  of  excitement.  Counter-irri- 
tation might  be  used  if  there  is  doubt  as  to  the  abscess 
having  been  formed  ;  mercury,  by  mouth  or  inunction, 
is  strongly  advised.  Cold  may  be  applied  continu- 
ously. 

More  benefit  can  be  hoped  from  the  use  of  precau- 
tions to  prevent  the  formation  of  an  abscess.  Otorrhoea 
should  never  be  neglected,  especially  in  children ;  an 
effort  should  be  made  to  cure  the  local  disease. 

When  there  has  been  severe  injury  to  the  head,  rest 
and  quiet  should  be  maintained  for  a  while,  and,  if 
there  is  attendant  headache,  the  enforced  quiet  should 
be  kept  up  till  that  disappears  ;  during  this  time  the 
diet  should  be  sufficient,  but  light,  easily  digested,  and 
unstimulating  ;  cold  applied  continuously,  and  leeches 
may  be  used.     Free  action  of  the  bowels  by  cathartics. 

The  question  of  trephining  in  injuries  to  the  skull 
belongs  to  surgery. 


DISEASES  OF  THE  SPINAL  CORD. 


CHAPTER  IX. 

ANATOMY,    PHYSIOLOGY,    AND   GENEEAL   SYMPTOM- 
ATOLOGY. 

Bramwell,  Byrom,  The  Diseases  of  the  Spinal  Cord.  New 
York,  Wm.  Wood  &  Co.,  1882.— Althaus,  Julius,  On  Sclerosis  of 
the  Spinal  Cord.  New  York,  1885.— Schuster,  Diagnostik  der 
Eiickenmarks-Krankheiten.  Berlin,  1884. — Charcot,  J.  M.,  Lect- 
ures on  the  Diseases  of  the  Nervous  System.  2d  Series.  New  Syden- 
ham Soc,  1881.  Lectures  on  the  Localization  of  Cerehral  and 
Spinal  Disease.  Ibid.,  1883. — Leyden,  E.,  Klinik  der  Eiicken- 
marks-Krankheiten. Berlin,  1874. — Page,  H.  W,,  Injuries  of  the 
Spine  and  Spinal  Cord.  London,  1883. — Vulpian,  A.,  Maladies 
de  la  moelle.  Paris,  1879.— Buzzard,  Thomas,  Clinical  Lecture 
on  Diseases  of  the  Nervous  System.  Philadelphia,  1882. — Drum- 
MOND,  David,  Diseases  of  the  Brain  and  Spinal  Cord.  London, 
1883. — GowERS,  W.  R.,  The  Diagnosis  of  Diseases  of  the  Spinal 
Cord.  Philadelphia,  1884.— Seguin,  E.  C,  The  Localization  of 
Diseases  in  the  Spinal  Cord.  Opera  Minora.  New  York,  1884, 
p.  436  ;  also  p.  283. — Schiefferdecker,  Beitrage  zur  Kenntniss 
des  Faserverlaufs  im  Riickenmark.  Arch.  f.  mikrosJcopische 
Anatomie,  Bd.  10,  H.  4,  p.  471. — HoLLis,  W.  A.,  Researches  into 
the  Histology  of  the  Central  Gray  Substance  of  the  Spinal  Cord 
and  Medulla  Oblongata.  Journal  of  Anatomy  and  Physiol., 
July,  1883. — Ranney,  A.  L.,  The  Applied  Anatomy  of  the  Nerv- 
ous System.  New  York,  1881. — Ibid.,  The  Architecture  of  the 
Spinal  Cord  and  its  Relations  to  Medicine.  New  YorJc  Med.  Jour., 
1884.  —  Ad AMKIEWIEZ,  A. ,  Die  Blutgef asse  des  menschlichen 
Riickenmarkes.  Stzsbrct.  derJc.  AJcad.  der  Wiss.,  Wien,  Lxxxiv, 
1881,  Ixxxv,  1882.  See,  also,  Ross,  Erb,  in  Ziemssen's  Cyclopaedia, 
vol.  xiii,  Leyden,  Drummond,  etc. — Brown-Sequard,  C.  E.,  Lect- 
ures on  the  Physiology  and  Pathology  of  the  Central  Nervous 
System.  Philadelphia,  I860.— Stirling,  William,  On  the  Reflex 
Functions  of  the  Spinal  Cord,  Edinburgh  Med.  Jour.,  April, 
1876,  p.  914. — Purser,  J.  M.,  On  the  Anatomy  and  Physiology 
of  the  White  Tracts  of  the  Spinal  Cord.     Dublin  Jour,  of  Med. 


132  DISEASES  OF  THE  SPINAL    CORD. 

Set.,  1878.— Ott,  J.,  and  Smith,  E.  M.,  The  Paths  of  Conduc- 
tion of  Sensory  and  Motor  Impulses  in  the  Cervical  Segment  of 
the  Spinal  Cord.  Am.  Jour.  Med.  Sci.,  Oct.,  1879,  p.  438. — 
Stakr,  M.  Allen,  Localization  of  the  Functions  of  the  Spinal 
Cord.  Am.  Jour,  of  Neurol,  and  Psych.,  Aug.  and  Nov.,  1884, 
p.  443. — Ibid.,  The  Sensory  Tract  in  the  Central  Nervous  System. 
Jour,  of  Nervous  and  Ment.  Diseases,  July,  1884,  p.  327. — See, 
also,  Eoss,  Erb,  etc. 

ANATOMY. 

The  membranes  of  tTie  spinal  cord  are  usually  de- 
scribed as  three — the  dura  mater,  araclinoid,  and  pia 
mater.  The  dura  mater  is  double,  the  outer  portion 
forming  a  periosteum  for  the  vertebrae  ;  the  inner  layer 
is  connected  with  the  outer  by  loose  connective  tissue, 
containing  fat  and  blood-vessels.  This  inner  layer  is 
the  portion  usually  referred  to  in  speaking  of  the  dura 
mater. 

Opinions  differ  as  to  the  arachnoid :  some  authors 
consider  it  as  forming  part  of  the  other  two  membranes, 
while  others  regard  it  as  a  distinct  membrane. 

The  pia  mater  is  closely  adherent  to  the  cord,  and 
through  it  run  the  nutrient  vessels  for  the  cord.  It 
sends  processes  into  the  fissures  of  the  cord ;  it  sur- 
rounds the  nerve-roots  in  their  course  from  the  cord  to 
the  dura  mater.  From  the  pia  mater,  on  each  side, 
arises  the  ligamentum  denticulatum,  which  keeps  the 
spinal  cord  in  the  center  of  the  spinal  canal.  It  runs 
the  whole  length  of  the  cord,  and  stays  it,  by  means  of 
twenty  to  twenty-three  teeth-like  processes,  to  the  dura 
mater. 

The  space  between  the  pia  mater  and  dura  mater  is 
filled  with  the  cerebro-spinal  fluid,  which  is  contained 
in  a  very  loose,  wide-meshed  connective  tissue. 

The  spinal  cord  is  then  suspended  in  the  cerebro- 
spinal fluid  by  means  of  many  processes  of  the  pia 
mater,  by  the  nerve-roots,  and  the  posterior  septa.  This 
suspension  is  so  contrived  that  the  influence  of  jars 
and  shocks  may  be  reduced  as  much  as  possible. 


ANATOMY.  133 

The  anastomoses  between  the  arteries  on  the  surface 
of  the  cord  are  very  free,  especially  in  the  cervical  and 
lumbar  portions,  least  so  in  the  dorsal  region.  The 
smaller  arteries  in  the  interior  of  the  cord  anastomose 
quite  freely.  The  central  gray  substance  and  internal 
parts  of  the  cornua  are  supplied  chiefly  by  one  set  of 
vessels  ;  the  white  substance  and  outer  part  of  the  cor- 
nua by  another.  The  gray  substance  has  a  larger  blood- 
supply  than  the  white. 

The  cord  extends  lower  in  women  than  in  men — in 
the  former  reaching  the  second  lumbar  vertebra,  in  the 
latter  only  the  first.  In  men  the  proportion  between 
the  cord,  the  vertebral  column,  and  the  length  of  the 
body,  is  1 : 1'62  :  3 '76  ;  in  women  the  same  proportion  is 
1:1-56:  3-58. 

The  gray  matter  is  arranged  around  a  central  cavity 
called  the  central  canal,  which  extends  throughout  the 
length  of  the  cord.  Two  processes  project  forward,  one 
on  either  side,  called  the  anterior  cor  nit;  two  similar 
processes  project  backward,  one  on  either  side,  called 
the  posterior  cornu.  The  gray  matter  is  relatively 
larger,  and  the  cornua  are  thicker,  in  the  cervical  and 
lumbar  enlargements,  and  smaller  in  the  dorsal  region. 
In  the  anterior  cornua  are  large  nerve-cells,  with  many 
processes  arranged  approximatively  in  groups — the  in- 
ternal, the  anterior,  the  antero-lateral,  the  postero-lat- 
eral,  and  central.  Lockhart  Clarke  gave  the  name  trac- 
tus  intermedio  lateralis  to  a  group  of  cells  correspond- 
ing to  the  postero-lateral  group  mentioned  above.  At 
the  junction  of  the  posterior  cornua  with  the  central 
gray  matter  there  is  found  also,  at  certain  levels,  a 
group  of  cells  of  very  nearly  equal  size  ;  these  cells 
are  nearly  spherical,  with  only  one  process.  Scattered 
among  these  are  smaller  cells,  usually  fusiform  in  shape ; 
this  group  is  called  the  internal  vesicular  columns  by 
Clarke  ;  many  authors  name  it  Clarke's  column. 

The  posterior  cornua  are  formed  of  two  varieties  of 
structure,  the  spongy  portion  near  the  central  gray  sub- 


134  DISEASES  01   TEE  SPINAL   CORD. 

stance,  the  gelatinous  substance  posterior  to  tlie  former, 
and  running  forward  on  each  side  of  it,  haviijg  the 
form  of  an  irregular  crescent.  A  few  large  nerve-cells, 
with  many  processes,  are  found  scattered  through  the 
gelatinous  substance,  especially  along  its  outer  border. 
The  nerve-cells  in  the  spongy  portion  are  rarely  of 
large  size.  In  the  posterior  cornua  are  found  also  some 
of  the  smallest  cells  belonging  to  the  spinal  cord.  The 
opposite  sides  are  connected  in  front  of  the  central  canal 
by  nerve-fibers  forming  the  anterior  or  white  commis- 
sure ;  behind  the  central  canal  is  a  commissure  formed 
of  gray  matter — the  posterior  or  gray  commissure. 

The  white  substance  of  the  spinal  cord  is  divided 
into  two  lateral  halves  by  an  anterior  and  posterior 
fissure.  The  anterior  fissure  is  the  better  marked,  and 
extends  about  one  third  through  the  cord  to  the  white 
commissure.  The  posterior  fissure  is  not  quite  so  deep 
as  the  anterior,  and  is  less  well  marked  ;  sometimes,  in- 
deed, its  position  is  only  indicated  by  a  small  blood- 
vessel in  a  narrow  band  of  connective  tissue. 

Each  half  of  the  white  substance  is  roughly  divided 
by  the  anterior  and  posterior  cornua  into  three  col- 
umns— the  anterior,  lateral,  and  posterior.  The  ante- 
rior and  lateral  are  frequently  spoken  of  together  as 
the  antero-lateral  column.  The  posterior  column  is 
divided  into  two  portions  by  a  septum  of  connective 
tissue,  usually  containing  blood-vessels,  situated  at  a 
variable  distance  exterior  to  the  posterior  fissure.  The 
column  between  this  septum  and  the  posterior  fissure  is 
called  the  internal  posterior  column,  or  more  frequently 
the  column  of  Gfoll.  The  nerve-fibers  in  this  column 
are  on  an  average  the  smallest  in  the  cord.  This  divis- 
ion of  the  posterior  column  is  seen  throughout  the 
length  of  the  cord,  but  the  internal  portion  gradually 
diminishes  in  size  downward,  and  in  the  lumbar  region 
mere  traces  of  it  are  found.  The  portion  on  each  side 
between  the  lateral  septum  and  the  posterior  cornu  is 
called  the  external  posterior  column,  or  more  frequently 


AN-ATOMY.  135 

the  external  radical  column  or  posterior  root-zone,  or 
column  of  Burdach.  The  anterior  column  is  also  di- 
vided into  two  portions,  but  with  less  definiteness  than 
the  posterior  column.  There  is  a  narrow  band  along 
the  edge  of  the  anterior  fissure,  which,  physiologically 
and  pathologically,  is  distinct  from  the  rest  of  the  an- 
terior column.  This  is  called  the  direct  pyramidal  col- 
umn, or  column  of  Tiirck ;  this  column  can  be  traced 
upward  to  the  crus  cerebri  of  the  same  side  without 
decussating.  In  the  lateral  column  there  is  also  a  dis- 
tinct group  of  fibers  called  the  lateral  pyramidal  tract, 
which  occupies  about  the  center  of  the  lateral  column, 
in  the  cervical  region,  having  the  cerebellar  fibers  along 
its  outside.  In  the  lower  dorsal  and  lumbar  regions 
these  cerebellar  fibers  gradually  diminish  in  thickness 
until  they  disappear  ;  hence  the  pyramidal  fibers  come  to 
the  surface.  The  white  substance  around  the  extremi- 
ties of  the  anterior  cornua  may  be  called  the  anterior 
root-zones. 

The  pyramidal  fibers  in  both  the  anterior  columns 
and  the  lateral  columns  can  be  traced  from  the  brain. 
Arising  from  the  motor  centers  in  the  brain,  they  pass 
through  the  anterior  two  thirds  of  the  posterior  seg- 
ment of  the  internal  capsule,  the  middle  of  the  crusta 
(basis)  of  the  crus  cerebri,  through  the  pyramidal  re- 
gion of  the  pons  and  medulla  to  the  anterior  pyramids. 
In  the  anterior  pyramids  the  fibers  intended  for  the 
lateral  columns  decussate  and  pass  down  the  opposite 
half  of  the  cord  ;  the  direct  fibers  do  not  decussate,  but 
pass  down  the  anterior  columns  on  the  same  side,  next 
the  anterior  fissure. 

It  may  be  mentioned  here  that  the  divisions  above 
described  are  differentiated  physiologically,  pathologi- 
cally, and  in  some  cases  anatomically  ;  and  also  by  the 
fact  that  the  nerve-fibers  in  the  different  portions  ac- 
quire a  medullary  sheath  at  different  periods  of  devel- 
opment, as  has  been  demonstrated  by  Flechsig,  Ross, 
Charcot,  Parrot,  and  others. 


136  DISEASES  OF  TEE  SPINAL   CORD. 

The  anterior  nerve-roots  enter  the  cord  opposite  the 
anterior  cornua.  Before  entering  the  cord,  the  roots 
split  up  into  small  bundles  of  nerve-fibers,  which  are 
distributed  laterally  over  a  space  corresponding  in  ex- 
tent with  the  width  of  the  anterior  cornua.  These 
fibers  pass  directly  through  the  white  substance  into 
the  gray  matter,  or  take  a  longitudinal  direction  for  a 
short  distance,  and  then  pass  into  the  anterior  cornua. 
The  posterior  nerve-roots  enter  the  cord  near  together 
on  a  vertical  line ;  some  of  the  fibers  pass  directly 
into  the  posterior  cornua,  but  most  of  them  pass  into 
the  external  radical  column,  and  enter  the  posterior 
cornua  at  different  levels.  Some  fibers  pass  directly  into 
the  vesicular  columns,  and  some  of  these  pass  forward 
to  one  of  the  groups  of  anterior  cells.  Some  of  the 
fibers  of  the  white  columns  run  long  distances  before 
entering  the  gray  substance  ;  such  are  the  fibers  in  the 
anterior  and  lateral  pyramidal  columns,  the  columns  of 
Goll,  and  the  cerebellar  fibers.  Other  fibers  run  only  a 
short  distance,  serving  as  commissural  fibers  for  the 
gray  substance  at  different  levels. 

PHYSIOLOGY   OF   THE  SPINAL   CORD. 

The  spinal  cord  is  not  a  simple  organ,  as  must  be 
realized  from  the  brief  account  of  its  anatomy ;  the 
functions  it  is  intended  to  fulfill  are  many,  and  its 
physiology,  consequently,  is  complicated.  We  are  jus- 
tified, then,  in  considering  the  cord,  not  as  one  simple 
organ,  but  as  a  series  of  organs  having  somewhat  dif- 
,  ferent  functions.  The  cord  may  be  divided,  theoreti- 
cally, into  as  many  sections  as  there  are  pairs  of  nerves 
arising  therefrom,  and  each  section  be  regarded  as  a 
distinct  unit  connected  with  its  fellows  by  commissural 
fibers ;  or  it  may  be  viewed  as  several  different  nerve- 
entities  arranged  side  by  side  longitudinally,  each  indi- 
vidual connected  with  the  others  by  transverse  commis- 
sures. Sometimes  one  view  will  be  most  convenient  for 
understanding  phenomena,  and  sometimes  the  other. 


PHYSIOLOGY  OF  THE  SPIKAL   COED.  I37 

The  groups  of  nerve-cells  in  the  gray  substance  act 
as  centers  of  nervous  influence,  more  or  less  independ- 
ent. Those  in  the  anterior  cornua  are  connected  with 
the  nerve-fibers  of  the  anterior  roots,  and  serve  as  media 
by  which  motor  impulses  are  communicated  through 
the  nerves  to  the  muscles,  whether  those  impulses  come 
from  the  brain  or  from  the  sensory  nerves  of  the  poste- 
rior roots — that  is,  whether  they  are  volitional  or  reflex. 
Attempts  have  been  made  to  assign  different  nerve- 
groups  to  certain  muscles ;  while  this  can  be  roughly 
approximated,  as  yet  much  that  has  been  written  in 
regard  to  such  a  division  of  function  is  theoretical. 

Among  these  cells  are  to  be  found  also  centers  of 
nutrition,  trophic  centers  for  both  nerves  and  muscles. 
It  is  not  yet  settled  whether  distinct  nerve-cells  have 
this  function,  or  whether  it  is  exercised  by  the  motor 
cells;  as  Ferrier  expresses  the  thought,  "We  have  as 
units  of  external  function  certain  nerve-centers,  cen- 
trifugal nerves,  and  peripheral  organs,  muscular,  gland- 
ular, and  their  adjuncts.  In  union  they  exhibit  certain 
vital  properties  and  reactions  which  we  call  normal. 
.  .  .  But  dissolve  the  unity,  and  the  tissues  are  left 
to  their  own  powers  of  nutrition,"  and  various  forms  of 
degeneration  are  seen. 

The  posterior  cornua  are  known  to  belong  to  the 
sensory  portion  of  the  cord.  Their  cells  are  in  some 
way  concerned  in  transmitting  sensory  impressions  to 
the  brain,  or  in  transferring  them  into  reflex  phenome- 
na ;  perhaps  they  intercept  some  impressions  and  utiliz- 
ing them  for  stimulating  vital  processes,  do  not  permit 
such  impressions  to  reach  the  brain  unless  they  are  un- 
usually strong.  The  sense  of  pain  is  conveyed  specially 
by  the  posterior  gray  substance,  and  a  very  small  sec- 
tion of  this  is  sufficient  to  transmit  pain ;  when  the  pos- 
terior columns  are  diseased,  probably  some  of  the  ordi- 
nary sensations  pass  through  the  gray  substance  by 
unusual  paths ;  hence,  perhaps,  the  delay  sometimes 
noticed  in  conduction  of  sensation. 


138  DISEASES  OF  THE  SPINAL   COED. 

Sensations,  whether  of  pain  or  the  ordinary  sensa- 
tions, after  entering  the  cord  by  the  posterior  nerve- 
roots,  soon  pass  to  the  opx^osite  side  and  then  ascend 
to  the  brain. 

The  white  columns  are  commissural ;  some  connect 
the  brain  with  different  groups  of  cells,  others  connect 
these  groups  of  cells  with  one  another. 

The  pyramidal  tracts  connect  the  motor  areas  of  the 
brain  with  the  groups  of  cells  in  the  anterior  cornua — 
the  lateral  pyramidal  tracts  decussating  in  the  anterior 
pyramids,  the  direct  passing  down  without  decussation. 
The  fibers  which  govern  the  respiratory  muscles  seem  to 
pass  down  in  the  lateral  columns  without  decussation. 

The  anterior  root-zones  are  commissural,  and  are  con- 
cerned specially  in  reflex  actions,  and,  perhaps,  in  co- 
ordinating the  action  of  nerve-cells  at  different  levels. 

The  posterior  columns  are  sensory.  The  external 
radical  columns,  columns  of  Burdach,  are  probably 
chiefly  commissural,  and  are  employed  for  co-ordina- 
tion of  the  sensory  impressions  and  translation  of  these 
into  reflex  or  semi-reflex  acts.  Many  of  the  fibers  of 
the  posterior  nerve-roots  pass  upward  or  downward  in 
these  before  they  enter  the  posterior  cornua. 

The  fibers  of  the  columns  of  GoU  pass  upward 
toward  the  brain  ;  their  mode  of  termination  and  func- 
tion are  not  known. 

The  posterior  columns  in  one  or  both  of  its  divisions 
transmit  the  ordinary  sensations — touch,  temperature, 
pressure,  etc. — but  not  the  sensation  of  pain. 

The  direct  cerebellar  tract  is  composed  of  ascending 
fibers,  and  is  said  to  be  connected  with  Clarke's  vesicu- 
lar column  at  the  root  of  the  posterior  cornua.  Its 
function  is  not  known. 

GENERAL   SYMPTOMATOLOGY. 

It  will  be  convenient  to  mention  the  groups  of  symp- 
toms which  indicate  lesion  of  certain  regions  of  the 
spinal  cord. 


GENERAL  SYMPTOMATOLOGY.  I39 

Total  paralysis  of  motion,  sensation  not  being  af- 
fected, points  to  lesion  of  the  antero-lateral  columns 
and  anterior  cornua.  If  the  paralysis  is  unilateral,  it 
will  be  on  the  same  side  with  the  lesion. 

If,  in  disease  of  the  cord,  there  is  simply  paralysis, 
without  marked  wasting  or  change  of  electrical  reaction 
in  the  muscles,  provided  time  enough  has  elapsed  since 
its  origin,  neither  the  anterior  cornua  nor  the  nerve- 
roots  at  the  level,  whence  arise  the  nerves  supplying 
the  paralyzed  muscles,  can  be  affected. 

If  besides  paralysis  there  is  spasm,  contracture,  and 
increased  reflex  action  in  the  affected  limbs,  without 
pain,  the  lateral  columns  are  affected.  The  anterior 
columns  may  be  diseased  too,  but  the  symptoms  would 
not  necessarily  indicate  it.  The  spasmodic  phenomena 
and  increase  of  reflex  action  follow,  whether  the  lesion 
of  the  lateral  columns  is  primary  or  secondary. 

If,  in  disease  of  the  spinal  cord,  with  the  paralysis, 
there  is  also  wasting  of  the  paralyzed  muscles  and  loss 
or  great  diminution  of  reaction  to  the  faradic  current, 
still  more  if  there  is  increased  reaction  to  the  galvanic 
current,  with  reversal  of  qualitative  reaction  (degen- 
erative reaction),  the  lesion  is  either  in  the  anterior 
nerve-roots  or  in  the  anterior  cornu.  It  is  rare  to 
have  the  anterior  nerve-roots  affected  as  they  pass 
through  the  anterior  columns,  unless  the  lesion  is  trau- 
matic in  its  origin.  Unless  the  anterior  cornu  is  dis- 
eased over  a  considerable  length  of  the  cord,  the  paraly- 
sis is  local,  and  the  muscles  supplied  by  nerves  arising 
below  the  seat  of  the  lesion  are  healthy.  When  only  a 
few  muscles  are  affected,  especially  if  they  form  a  group 
which  physiologically  act  together,  the  disease  may  be 
limited  to  a  very  small  area. 

Ferrier  ("The  Localization  of  Atrophic  Paralyses," 
"Brain,"  vol.  iv,  1881-82,  p.  226)  giVes  the  muscles  sup- 
plied by  the  different  nerves  of  the  brachial  and  lumbar 
plexuses.  Some  of  the  muscles  mentioned  are  supplied 
by  fibers  from  more  than  one  nerve ;  only  that  nerve 


140  DISEASES  OF  THE  SPINAL   CORD. 

giving  tlie  largest  proportion  of  fibers  is  mentioned. 
The  enumeration  can  be  considered  as  only  approxi- 
mately correct ;  yet  it  will  serve  as  an  aid  in  locating  a 
lesion  in  tlie  spinal  cord,  and  perhaps  wiU  prove  of 
most  value  where  there  is  atrophy  of  muscles.  As  the 
skin  over  muscles  is  supplied  by  nerve-fibers  from  near- 
ly the  same  region  as  the  muscles,  the  distribution  of 
anaesthesia  may  serve  roughly  as  a  guide  to  diagnosis 
of  the  level  of  a  lesion,  though  in  such  a  case  much  less 
likely  to  be  so  nearly  correct  as  when  muscular  symp- 
toms are  the  guide.  ^ 

The  first  dorsal :  The  intrinsic  muscles  of  the  hand, 
viz.,  muscles  of  the  thenar  and  hypothenar  eminences 
and  interossei. 

Eighth  cervical :  Long  flexors,  ulnar  flexors  of  wrist, 
intrinsic  muscles  of  the  hand,  extensors  of  wrist  and 
phalanges,  long  head  of  triceps  (pectoralis  major  ?). 

Seventh  cervical :  Teres  major,  latissimus  dorsi,  sub- 
scapularis,  pectoralis  major,  flexors  of  wrist  and  fingers 
(median),  triceps. 

Sixth  cervical :  Latissimus  dorsi,  pectoralis  major, 
serratus  magnus,  pronators  (flexor  of  wrist  1),  triceps. 

Fifth  cervical :  Deltoid  (clavicular  portion),  biceps, 
brachialis  anticus,  serratus  magnus,  supinator  longus, 
extensors  of  wrist  and  fingers. 

Fourth  cervical :  Deltoid,  rhomboid,  supra-  and  in- 
fra-spinatus  (teres  minor),  biceps,  brachialis  anticus, 
supinator  longus,  extensors  of  wrist  and  fingers,  dia- 
phragm. 

In  the  lower  extremity  : 

Second  sacral :  Intrinsic  muscles  of  the  foot,  strictly 
parallel  to  the  first  dorsal. 

First  sacral :  Muscles  of  the  calf  (plantar  flexors), 
hamstrings,  long  flexor  of  big  toe,  intrinsic  muscles  of 
the  foot. 

*  See,  also,  M.  Allen  Starr,  "  Localization  of  the  Functions  of  Spinal 
Cord,"  "  Amer.  Jour,  of  Neurolog.  and  PsycMat.,"  August  and  Novem- 
ber, 1884,  p.  480. 


GENERAL  SYMPTOMATOLOGY.  141 

Fifth  lumbar :  Flexors  and  extensors  of  toes,  tibial 
muscles,  sural  muscles,  peroneal  muscles,  outward  ro- 
tators of  thigh,  hamstrings. 

Fourth  lumbar :  Extensors  of  thigh,  extensor  cruris, 
peroneus  longus,  adductors. 

Third  lumbar:  Ilio-psoas,  sartorius,  adductors,  ex- 
tensor cruris. 

By  keeping  this  general  scheme  in  mind,  an  idea 
may  be  formed,  nearly  correct,  of  the  level  of  the  lesion, 
and  a  record  may  be  made  by  which  to  judge  whether 
it  is  extending  or  receding. 

A  study  or  examination  of  the  various  reflexes  will 
also  aid  in  the  formation  of  a  diagnosis  of  locality.  (See 
page  8.) 

There  may  not  be  paralysis,  yet  the  motor  conduct- 
ors may  be  seriously  affected,  so  that,  while  all  motions 
are  possible,  yet  there  is  clearly  a  loss  of  strength,  and 
the  movements  are  very  slow ;  there  is  a  retardation  of 
the  motor  conduction ;  Burckhardt  thinks  this  points 
to  disease  of  the  white  columns. 

Burckhardt  has  also  studied  the  acceleration  of  mo- 
tor conduction.  This  is  not  very  rare,  but  is  more  dif- 
ficult to  recognize.  Some  cases  of  exaggerated  reflex 
action  may  be  due  to  this  condition.  Burckhardt  refers 
this  phenomenon  to  an  affection  of  the  gray  substance. 

There  may  be  no  paralysis,  but  the  motions  may  be 
irregular  ;  there  is  a  loss  of  co-ordinating  power,  a  con- 
dition known  as  ataxia,  which  Erb  defines  as  "the  dis- 
turbance of  movement,  produced  by  defective  co-ordi- 
nation of  movement."  He  considers  that  it  is  of  a 
motor  nature.  While  all  motions  may  be  performed 
with  power,  the  patient  can  not  execute  any  movement 
with  precision ;  the  hand  or  foot  is  carried  beyond  or 
falls  short  of  the  point  it  is  desired  to  touch,  or  it  is 
carried  to  one  side.  In  attempting  to  grasp  an  object, 
the  strength  put  forth  is  out  of  proportion  to  the  end 
to  be  gained.  When  extreme,  this  ataxia  may  be 
shown  in  all  the  motions  ;  if  the  defect  is  but  slight,  it 


142  DISEASES  OF  TEE  SPINAL   CORD. 

may  be  necessary  to  ask  the  patient  to  close  Ms  eyes 
before  tlie  symptom  can  be  clearly  recognized.  When 
the  aid  of  sight  is  withdrawn,  the  patient  may  be  un- 
able to  touch  a  certain  part  of  his  face,  as  the  chin  or 
end  of  the  nose,  with  his  forefinger,  or  in  walking  may 
be  unable  to  propel  his  feet  properly.  Yet  not  every 
defect  in  walking  with  closed  eyes  is  due  to  ataxia ; 
weakness  may  cause  a  patient  to  totter  and  walk  irregu-. 
larly  ;  vertigo  may  have  a  similar  effect ;  anaesthesia  of 
the  sole^  of  the  feet  or  of  the  joints  may  cause  a  patient 
to  stagger  when  the  eyes  are  closed. 

Erb  thus  describes  the  ataxic  gait:  "It  is  charac- 
terized by  irregular  hurling  movements ;  the  point  of 
the  foot  is  thrown  forward  and  outward  with  force  ; 
the  heel  is  brought  down  with  a  stamp,  the  leg  stiff  at 
the  knee.  The  patient's  eyes  are  continually  on  the 
ground.  The  gait  is  tottering,  staggering,  or  even  reel- 
ing from  side  to  side ;  the  movements  are  hasty,  spas- 
modic, quite  unequal ;  in  turning  about,  especially, 
there  is  great  uncertainty,  and  danger  of  falling.  In 
severe  cases  the  patient  falls  after  a  few  steps."  This 
accurate  description  applies  to  rather  advanced  cases  ; 
there  may  be  only  a  very  slight  degree  of  disturbance 
early  in  the  disease. 

This  ataxic  condition,  when  dependent  upon  disease 
of  the  spinal  cord,  is  the  result  of  changes  in  the  pos- 
terior columns,  and  more  definitely  the  external  radical 
columns. 

Involuntary  muscular  movements  are  among  the 
prominent  symptoms  in  certain  affections  of  the  spinal 
cord.  These  are  of  a  reflex  nature,  or  the  result  of 
direct  irritation  of  the  motor  roots  or  motor  regions  of 
the  cord. 

When  the  spinal  cord  is  divided,  or  when  destruc- 
tion by  disease  extends  across  the  cord,  so  that  commu- 
nication with  the  brain  is  cut  off,  reflex  movements  are 
exaggerated  in  all  parts  of  the  body  below  the  seat  of 
injury  whose  reflex  nervous  arc  remains  intact.    The 


GENERAL  SYMPTOMATOLOGY.  14 3 

reflex  phenomena,  as  mapped  oufc  by  Gowers,  may  as- 
sist, then,  in  locating  the  seat  of  the  disease.  (See 
above,  p.  8.) 

When  there  is  increased  irritability  of  the  gray  sub- 
stance, the  reflex  motions  in  the  regions  supplied  by 
nerves  arising  therefrom  will  be  exaggerated.  The 
same  exaggeration  is  found  in  disease  of  the  lateral 
pyramidal  columns,  as  in  secondary  degenerations  and 
sclerosis. 

The  pupillary  reactions  are  reflex :  if  the  cervical 
region  of  the  cord  is  destroyed,  the  pupils  may  be  con- 
tracted ;  if  there  is  irritation,  they  will  be  dilated.  The 
normal  reactions  will  not  be  present. 

Reflex  action  may  be  much  diminished  or  abolished 
when  any  portion  of  the  reflex  arc  is  diseased  ;  whether 
the  sensory  nerves  or  posterior  nerve-roots,  the  gray 
substance,  or  the  anterior  motor  regions,  or  motor 
roots,  are  diseased.  Reflex  action  may  be  delayed 
under  similar  conditions  under  which  sensory  impres- 
sions are  delayed. 

In  cerebral  disease  the  reflex  actions  may  be  abol- 
ished on  the  paralyzed  side. 

Westphal  first  called  attention  to  the  fact  that  the 
tendon  reflex  is  lost  at  an  early  period  in  locomotor 
ataxia ;  this  has  been  confirmed  by  others,  and  it  is 
now  generally  accepted  as  true  of  that  disease.  It  has 
been  found  absent  when  the  columns  of  Goll  were  not 
affected,  the  external  radical  columns  alone  being  dis- 
eased (Westphal).  It  is  also  lost  when  the  spinal  cord 
is  entirely  disorganized ;  when  the  sensory  or  motor 
roots  (or  peripheral  nerves)  are  destroyed ;  when  the 
anterior  cornua  are  diseased,  so  as  to  cause  muscular 
atrophy  ;  and  in  some  other  less  definite  conditions. 

The  tendon  reflex  may  be  greatly  exaggerated,  and 
may  be  then  readily  shown  in  connection  with  tendons 
with  which  it  is  not  usually  noticed,  as  those  of  the 
triceps  humeri,  of  the  fingers,  of  the  sterno-mastoid. 

This  increase  of  the  phenomenon  is  one  of  the  symp- 


144  DISEASES  OF  TEE  SPINAL   CORD. 

toms  attending  sclerosis  of  the  lateral  columns  ;  it  may 
be  present  also  after  injuries  giving  rise  to  spinal  con- 
cussion (Edes),  and  in  hysteria ;  it  is  sometimes  seen 
during  acute  febrile  diseases,  as  typhoid  fever.  As  a 
symptom  of  disease  of  the  spinal  cord,  it  is  most  regu- 
larly associated  with  disease  of  the  lateral  columns, 
and  we  are  not  yet  able  to  say  that,  when  found  in  ap- 
parently exceptional  relations,  it  is  not  dependent  upon 
a  change  thus  located. 

Ankle  clonus  is  indicative  of  change  in  the  lateral 
pyramidal  columns.  Gowers  says  that  a  persistent  an- 
kle clonus  is  always  pathological ;  in  this  he  is  proba- 
bly a  little  too  emphatic,  but  its  presence  must  be 
looked  upon  as  strongly  in  favor  of  organic  changes  in 
the  cord. 

The  spinal  cord,  by  a  reflex  mechanism,  exerts  a 
control  over  the  bladder  and  rectum ;  the  will  also 
regulates  in  some  measure  those  viscera.  When  the 
contents  of  the  bladder  and  rectum  are  sufficient  to 
excite  reflex  action  in  their  expulsory  muscles,  the 
sphincters  relax,  probably  in  consequence  of  an  inhibi- 
tory action  of  the  spinal  centers,  and  an  evacuation  fol- 
lows. The  will  can  restrain  for  a  while  this  expulsive 
action,  or  can  excite  it  before  the  reflex  action  would 
arise  normally. 

If  the  spinal  cord  is  destroyed  above  the  lumbar 
enlargement,  this  voluntary  control  is  lost,  and  then  the 
contents  of  the  viscera  are  expelled  at  intervals  accord- 
ing as  the  reflex  centers  may  be  aroused  to  action  by 
the  irritation  excited  by  the  contents  of  the  viscera. 
The  patient  then  has  his  evacuations  involuntarily,  and 
without  knowing  that  they  occur. 

If  the  sensory  tract  alone  is  injured,  the  evacuations 
may  occur  without  his  knowledge,  but  he  will  have 
power  to  voluntarily  evacuate  the  viscera.  If  the  mo- 
tor tract  is  injured,  the  discharges  will  occur  without 
the  patient's  control,  but  he  will  be  conscious  of  the 
desire  to  evacuate  the  viscera,   and  will  know  when 


GENERAL  SYMPTOMATOLOGY.  I45 

the  evacuation  is  accomplished.  When  the  voluntary- 
control  is  weakened,  or  partially  lost,  while  the  sen- 
sory tract  is  unimpaired,  the  patient  is  obliged  to  re- 
spond quickly  to  the  calls  of  nature,  or,  the  restraining 
influence  of  the  will  being  slight,  involuntary  evacu- 
ation follows. 

As  the  centers  of  reflex  action  for  the  sphincters 
and  the  detrusor  muscles  are  not  identical,  one  may  be 
affected  independently  of  the  other  ;  then  there  will  be 
incontinence  when  the  sphincters  are  paralyzed,  reten- 
tion when  the  detrusors  are  paralyzed.  In  the  latter 
case,  the  sphincter  acting,  the  urine  accumulates  until 
it  may,  by  mere  mechanical  pressure,  overflow,  and  so 
there  may  seem  to  be  incontinence  when  there  is  really 
retention. 

Spasm  may  affect  the  sphincters  or  the  detrusors, 
and  corres]3onding  disturbances  will  follow. 

Perversion  of  the  sexual  functions  occur  in  many 
cases  of  spinal  disease,  much  more  marked  in  men 
than  in  women.  There  may  be  great  increase  of  sexual 
desire,  with»power  to  gratify  it ;  or  the  desire  may  be 
present  without  the  power,  or  with  greatly  diminished 
power  ;  or  there  may  be  frequent  nocturnal  or  diurnal 
emissions,  or  spermatorrhoea.  All  sexual  appetite  may 
be  lost,  and  there  may  be  complete  impotency.  Pria- 
pism, complete  or  partial,  may  continue  for  a  long  pe- 
riod. Among  women  a  similar  disturbance  of  sexual 
desire  may  occur,  but  these  symptoms  have  been  less 
fully  studied  than  among  men.  We  can  not  at  present 
draw  any  positive  conclusions  by  means  of  the  above 
variations  from  the  normal  condition. 

Yaso-motor  and  nutritive  changes  are  not  uncommon 
in  different  forms  of  spinal-cord  lesions.  The  simplest 
change  is  disturbance  of  capillary  circulation ;  the  af- 
fected parts  are  more  or  less  cyanotic,  or  they  may  be 
unnaturally  pale  ;  in  either  case  the  temperature  is  be- 
low normal ;  sometimes  there  is  great  increase  of  heat, 
with  less  apparent  disturbance  of  circulation.  In  one 
10 


146  DISEASES  OF  THE  SPINAL   COED. 

case  there  is  irritation  of  tlie  vaso-motor  centers,  in  the 
other  case  paralysis.  It  is  often  noticeable  that  para- 
lyzed limbs  are  slightly  oedematous,  and  sometimes  the 
consequent  swelling  is  very  great. 

The  skin  may  undergo  changes  similar  to  those  found 
In  neuritis  ;  there  may  be  a  scaly  condition,  due  to  ex- 
cessive multiplication  of  the  epidermic  cells ;  the  hair 
and  nails  may  suffer  in  nutrition  ;  herpetic  eruptions, 
pustules,  and  urticaria  may  be  noticed.  Bed-sores, 
chronic  or  acute,  are  the  most  troublesome  trophic 
changes  in  some  cases,  and  may  gradually  wear  out  the 
patient.  The  bones,  especially  their  articular  surfaces, 
undergo  changes  of  structure  and  form,  are  worn  away, 
or  become  brittle  and  easily  break. 

The  muscles  undergo  atrophy,  their  fibers  becom- 
ing reduced  to  rows  of  fat  drops  or  granules,  and 
finally,  these  being  absorbed,  only  the  sheaths  are  left ; 
sometimes  a  deposit  of  fat  between  the  muscular 
fibers  obscures  the  wasting,  and  the  affected  limbs 
retain  their  usual  proportions.  The  electrical  reac- 
tion of  degeneration  will  show  whether  this  atrophy 
has  occurred  and  enable  one  to  form  an  opinion  as 
to  how  far  it  has  advanced.  If  only  some  fibers  are 
degenerated,  these  reactions  may  be  obscured  and  less 
readily  obtained,  the  healthy  fibers  giving  the  normal 
reactions.  This  atrophy  shows  that  there  is  lesion  of 
the  motor  nerves  or  of  the  anterior  cornu  in  the  cord. 

The  general  nutrition  of  the  body  or  limbs  may  be 
altered  in  disease  of  the  spinal  cord  ;  there  may  be  great 
emaciation,  or  there  may  be  an  increased  deposit  of 
fat,  subcutaneous,  as  well  as  in  the  deeper  structures. 
When  the  nerve-cells  of  the  anterior  cornu  are  diseased 
in  infancy,  there  is  not  only  atrophy  of  the  muscles, 
but,  if  the  change  is  extensive,  the  paralyzed  limb  is 
retarded  in  its  subsequent  growth. 

The  anterior  part  of  the  central  gray  substance  is 
supposed  to  be  the  trophic  center  for  the  bones ;  the 
posterior  part  for  the  skin,  hair,  and  nails ;  the  ante- 


GENERAL  SYMPTOMATOLOGY.  147 

rior  cornua  are  tlie  trophic  centers  for  motor  nerves  and 
muscles. 

Sensation  is  entirely  lost  only  when  the  whole  of  the 
posterior  portion  of  the  cord,  including  the  gray  sub- 
stance, is  destroyed.  If  even  a  small  portion  of  the 
gray  substance  remains,  sensation  is  not  entirely  lost. 
It  is  probable  also  that  certain  parts  of  the  lateral  col- 
umns convey  sensation,  though  the  mode  of  distribution 
of  sensory  libers  in  these  columns  is  not  known.  When 
both  sides  are  destroyed,  a  narrow  band  of  hyperses- 
thesia  may  be  found  above  the  level  of  the  anaesthesia. 

If  only  one  side  of  the  cord  is  destroyed,  there  will 
be  hypersesthesia  below  the  seat  of  injury  on  the  same 
side  with  it,  and  anaesthesia  on  the  opposite  side ;  a 
narrow  zone  of  diminished  sensibility  on  both  sides  of 
the  body  will  be  found  at  the  level  of  the  injury,  and 
above  this  for  a  short  distance  there  may  be  hyperses- 
thesia  on  the  same  side  with  the  injury. 

When  sensation  is  not  entirely  destroyed,  the  differ- 
ent kinds  of  sensation,  as  touch,  temperature,  pressure, 
pain,  etc.,  may  be  affected  in  unequal  measure. 

When  there  is  not  destruction  of  the  cord,  there  may 
be  great  hypersesthesia,  and  the  increase  of  sensitive- 
ness may  be  so  great  that  even  a  slight  touch  causes 
great  suffering.  This  is  found  when  there  is  inflamma- 
tion of  the  meninges,  or  when  the  posterior  nerve-roots 
are  irritated,  as  by  compression,  and  rarely  in  inflamma- 
tion of  the  cord  itself,  though  local  hypersesthesia  is 
common  in  locomotor  ataxia,  especially  after  an  attack 
of  lancinating  pain. 

A  sensation  of  a  band  tied  around  the  body — a  girdle 
sensation  or  pain — is  frequently  found  in  myelitis,  and 
where  there  is  compression  of  the  cord.  It  is  difficult 
to  define  its  nature  ;  it  is  sometimes  painful,  sometimes 
simply  a  slight  sense  of  constriction.  It  is  seated  at 
the  level  of  distribution  of  the  nerves  arising  from  the 
upper  limit  of  the  disease  ;  sometimes  the  girdle  seems 
to  surround  one  or  both  legs  instead  of  the  body. 


148        '        DISEASES  OF  THE  SPINAL    CORD. 

When  the  posterior  nerve-roots  are  exposed  to  irri- 
tation, as  from  pressure  or  inflammatory  changes,  pain 
of  different  kinds  will  be  felt  at  the  peripheral  ends  of 
those  nerves  ;  if  the  nerves  are  suddenly  compressed  or 
bruised,  a  burning  sensation,  perhaps  very  painful,  will 
be  felt.  The  sensation  referred  to  the  periphery  in 
disease  of  the  spinal  cord  is  much  less  likely  to  be 
pain ;  it  rather  takes  the  form  of  tingling,  numbness, 
formication,  or  that  peculiar  sensation  known  as  being 
asleep. 

Backache  is  a  very  common  complaint  with  patients ; 
it  is  more  common  in  functional  than  in  organic  diseases. 
Tenderness  on  pressure  over  the  vertebrae  is  rare  in  or- 
ganic affections  ;  it  is  common  in  connection  with  cer- 
tain functional  disturbances. 


CHAPTER  X. 

SPIISTAL   MElSrilSrGITIS. 

JoFFROY,  A. ,  De  la  pachymeningite  cervicale  hypertropliique. 
Paris,  1873. — Spencer,  W.  H.,  Case  of  Idiopathic  Inflammation 
of  the  Spinal  Dura  Mater.  Lancet,  June  14,  1879,  p.  836. — Le- 
MOiNE,  G.,  and  Lannois,  N.,  Perimeningite  spinale  aigue.  Revue 
de  Med.,  No.  6,  1882. — Tooth,  Dorsal  pachymeningitis.  Brain, 
1884. 

There  are  two  subdivisions  of  spinal  meningitis — one 
affecting  the  dura  mater,  pachymeningitis;  the  other 
the  pia  mater,  leptomeningitis. 

External  pachymeningitis,  inflammation  of  the  ex- 
ternal surface  of  the  dura  mater,  is  caused  by  changes 
in  the  adjoining  parts — caries,  abscess,  cancer,  tumor, 
aneurisms  penetrating  from  without,  etc.  The  symp- 
toms will  be  so  united  with  those  caused  by  the  pri- 
mary disease  that  it  is  unnecessary  to  describe  them. 

PACHYMENINGITIS  INTERNA. 

Internal  pachymeningitis  may  occur  independently 
of  other  lesions.  Generally,  not  only  the  internal  sur- 
face of  the  dura  mater  is  affected,  but  its  whole  thick- 
ness may  be  the  seat  of  inflammatory  hypertrophy ;  the 
pia  mater  may  also  be  somewhat  thickened  and  in- 
flamed secondarily ;  it  can  usually  be  distinguished 
from  the  dura  mater. 

Owing  to  the  thickening  of  the  membranes,  the  cord 
is  compressed,  and  undergoes  inflammatory  changes ; 
sometimes  cavities  are  formed. 

The  nerve-roots  suffer  from  compression  and  second- 
ary inflammation  as  they  pass  through  the  dura  mater. 


150  DISEASES  OF  TEE  SPINAL    CORD. 

The  disease  is  confined  almost  exclusively  to  the 
cervical  region. 

Symptoms. — During  the  first  stage  of  the  disease 
the  prominent  symptom  is  pain  in  the  posterior  part  of 
the  neck  and  the  occipital  region  ;  following  the  direc- 
tion of  the  peripheral  nerves,  it  extends  frequently  in- 
to the  arms ;  it  is  aggravated  by  movements  of  the 
vertebrae,  sometimes  is  increased  by  firm  pressure  over 
the  spine,  and  at  times  is  extremely  severe.  Some- 
times before  the  pain  ceases,  more  frequently  after  a 
period  of  comparative  freedom  from  distress,  para- 
lytic symptoms  make  their  appearance,  first  weak- 
ness, which  gradually  increases  to  complete  paralysis. 
With  the  paralysis  there  is  atrophy  of  the  muscles. 
The  distribution  of  the  atrophy  is  somewhat  variable  ; 
the  muscles  of  the  hand,  the  interossei,  the  lumbricales, 
and  the  muscles  of  the  thenar  and  hypothenar  eminen- 
ces are  generally  greatly  atrophied  ;  in  the  forearm  the 
flexors  and  extensors  of  the  fingers,  the  flexors  and 
pronators  of  the  hand,  are  chiefly  affected  ;  the  muscles 
of  the  arm  generally  escape,  while  the  deltoid  and  the 
supra-  and  infra-spinatus  suffer.  Owing  to  the  atrophy 
of  some  muscles,  and  the  fact  that  others  are  unaffected, 
the  hand  acquires  an  unnatural  position  :  it  is  held  in 
a  position  of  extreme  extension,  with  the  fingers  par- 
tially flexed,  the  thumb  extended  and  adducted.  In 
some  cases  this  position  may  be  overcome  by  passive 
motion  ;  in  others  it  is  noticed  only  when  the  forearm 
is  in  supination. 

If  the  disease  affects  the  upper  part  of  the  cervical 
enlargement,  the  position  of  the  hand  is  different. 
Ross  thus  describes  the  position :  The  arm  is  held  close 
to  the  side,  the  forearm  is  extended  on  the  arm  and 
strongly  pronated,  the  hand  is  flexed  on  the  forearm, 
the  fingers  are  in  a  line  with  or  only  slightly  extended 
on  the  metacarpal  bones,  and  the  phalanges  are  ex- 
tended upon  one  another,  while  the  thumb  is  flexed 
into  the  palm.     The  muscles  supplied  by  the  musculo- 


PACEYMENINQITIS  INTERNA.  151 

spiral  nerve  are  more  affected  than  those  supplied  by 
the  ulnar  and  median. 

The  disease  has  rarely  been  observed  in  the  lower 
part  of  the  spine. 

The  paralyzed  muscles  undergo  atrophy,  and  the 
electrical  reaction  is  changed  ;  there  is  found  the  reac- 
tion of  degeneration,  or  entire  loss  of  electrical  reac- 
tion. 

Trophic  changes  in  the  skin,  vesicular,  bullous  erup- 
tions, dry  and  scaly  condition  of  the  skin,  and  a  glossy 
skin,  are  occasional  phenomena;  sometimes  bed-sores 
form.  The  temperature  is  frequently  lower  than  nor- 
mal. Slight  convulsive  shocks,  and  the  phenomena 
attending  lesion  of  the  lateral  columns,  are  sometimes 
met. 

Diagnosis. — The  first  stage,  where  there  is  only 
pain  without  impairment  of  motion,  is  difficult  of  diag- 
nosis. The  pains  may  be  referred  to  a  rheumatic  affec- 
tion, to  spinal  irritation  or  hysteria,  or  they  may  give 
rise  to  the  suspicion  that  caries  of  the  vertebrae  is  pres- 
ent. The  pain  due  to  pachymeningitis  is  said  to  be 
characterized  by  an  increase  during  movement  of  the 
vertebrae,  always  deeply  seated  in  the  back  part  of  the 
neck,  on  the  median  line  ;  frequency  of  the  attacks  of 
pain,  and  their  short  duration. 

When  muscular  atrophy  sets  in,  the  diagnosis  from 
progressive  muscular  atrophy  may  be  made  from  the 
history  of  the  preceding  attacks  of  pain,  from  the 
fact  that  the  muscles  are  affected  less  regularly ;  in 
muscular  atrophy  the  hand  will  assume  a  more  or  less 
flexed  position  when  in  the  stage  of  contracture,  but  in 
pachymeningitis  the  hand  is  extended  and  supinated, 
or  the  hand  and  arm  take  the  position  described  by 
Ross. 

Treatmeistt. — During  the  first  stage  the  most  press- 
ing indication  is  to  relieve  pain,  for  which  sedatives 
and  anodynes  may  be  used ;  hot  iron  applied  to  the 
neck  and  upper  part  of  the  dorsal  region  may  give  re- 


152  DISEASES  OF  THE  SPINAL   CORD. 

lief  to  the  pain,  and  may  also  act  favorably  upon  the 
progress  of  the  disease.  The  galvanic  current  along 
the  spine  has  been  recommended,  the  positive  pole 
above,  the  negative  pole  below,  the  cervical  region. 
Paralysis  and  atrophy  of  the  muscles  can  be  treated 
locally  by  the  faradic  or  galvanic  current. 

Internally,  iodide  of  potassium  may  be  given.  In 
judging  of  the  value  of  treatment,  it  should  be  remem- 
bered that  naturally  the  disease  has  periods  of  remis- 
sion. 

INFLAMMATION   OF   THE   PIA  MATER. 

Pathological  Anatomy. — The  term  spinal  menin- 
gitis is  commonly  used  to  designate  inflammation  of 
the  pia  mater,  leptomeningitis.  The  pia  mater  is  chief- 
ly affected;  it  is  found  congested,  thickened,  cedema- 
tous ;  upon  its  surface  and  within  its  meshes  there  is 
more  or  less  pus.  The  arachnoid  is  almost  always  im- 
plicated in  the  inflammatory  process ;  the  dura  mater 
is  also  sometimes  involved.  The  amount  of  pus  ex- 
uded varies  greatly  ;  it  may  be  so  little  as  merely  to  give 
a  yellowish  tinge  to  the  oedematous  membrane,  or  the 
surface  may  be  covered  with  a  thick,  creamy  layer. 
The  inflammation  may  extend  over  a  very  small  sur- 
face, or  may  affect  the  whole  cord.  In  about  one  third 
of  the  cases  there  is  coincident  cerebral  meningitis. 

After  the  exudation  has  been  absorbed,  there  may 
be  left  a  thickening  of  the  pia  mater  from  the  organi- 
zation of  the  inflammatory  products ;  the  membranes 
may  become  adherent  to  each  other,  though  this  is  rare. 

It  can  be  easily  understood  that  such  serious  dis- 
turbance of  the  pia  mater,  from  which  the  spinal  cord 
derives  its  blood-supply,  must  necessarily  involve  the 
spinal  cord,  and  we  almost  always  find  some  degree  of 
myelitis  associated  with  the  meningitis. 

iETioLoay. — The  principal  causes  are  exposure  to 
cold  and  dampness,  over-exertion  of  any  kind,  insola- 
tion, jars,  concussions,  falls  upon  the  back,  and  inflam- 


mFLAMMATIOIT  OF  THE  PI  A  MATER.  153 

mation  of  neighboring  parts.  Occasionally,  in  tubercu- 
lar meningitis,  tubercles  are  found  in  tlie  sxDinal  pia 
mater. 

SYMPTo:\rs. — Sometimes  a  short  prodromal  period  of 
general  discomfort  with  fugitive  pains  precedes  the  at- 
tack of  prominent  symptoms,  but  generally  the  disease 
commences  suddenly,  with  pain  in  the  back  and  pain 
radiating  into  the  limbs  ;  there  is  often  a  chill  and  the 
temperature  rises ;  there  may  be  headache  and  even 
vomiting,  though  this  is  rare,  unless  the  disease  is  near 
the  upper  part  of  the  spine  or  the  cerebral  membranes 
are  also  affected  ;  the  surface  of  the  body  becomes  ex- 
tremely sensitive  to  the  touch,  the  muscles  of  the  ex- 
tremities are  contracted,  the  body  may  be  in  position  of 
opisthotonus,  or  there  may  be  clonic  spasms  instead  of 
tonic  contraction  of  the  limbs. 

The  pain,  which  appears  early  in  the  back,  is  gener- 
ally very  severe,  is  increased  by  the  slightest  motion, 
whether  active  or  passive  ;  pressure  upon  the  vertebrae 
may  not  increase  it,  but  percussion  almost  always  does  ; 
extremes  of  temperature,  either  hot  or  cold,  produce 
pain  when  applied  over  the  region  affected.  The  pain 
may  radiate  around  the  trunk  in  the  form  of  a  girdle, 
though  this  is  perhaps  less  frequent  than  in  myelitis  ; 
it  may  also  radiate  with  extreme  severity  into  the  limbs. 
The  last  phenomena  are  due  to  irritation  of  the  nerve- 
roots.  The  cutaneous  hyperaesthesia  is  probably  due 
to  an  irritation  of  the  nerve-roots,  and  may  be  classified 
with  other  painful  manifestations ;  it  is  sometimes  so 
extreme  that  even  the  weight  of  the  bedclothes  causes 
torture  ;  not  only  the  limbs  but  the  trunk  may  be  thus 
affected,  and  the  muscles  and  bones  sometimes  show  an 
extreme  degree  of  sensitiveness. 

The  muscular  stiffness  and  rigidity  is  probably  at 
first  due  to  an  involuntary  tension  of  the  muscles  in 
order  to  avoid  motion  because  of  the  extreme  pain  pro- 
duced thereby  ;  later  the  contracture  is  probably  due 
to  direct  irritation  of  the  anterior  nerve-roots.     Some- 


154:  DISEASES  OF  THE  SPINAL    CORD. 

times,  especially  at  the  beginning  of  the  disease,  clonic 
spasms  add  to  the  patient's  suffering. 

There  is  generally  constipation  and  retention  of 
urine,  sometimes  with  a  frequent  desire  to  pass  it. 

Respiration  is  frequently  interfered  with,  especially 
when  the  disease  is  seated  in  the  cervical  region,  and 
death  sometimes  arises  from  this  disturbance  preceded 
by  Cheyne-Stokes's  respiration. 

When  the  contraction  diminishes  sufficiently,  it  is 
found  that  there  is  partial  or  total  paralysis,  and  that 
sensation  is  more  or  less  affected  ;  sometimes  with  pa- 
ralysis there  remains  contracture  of  the  limbs,  either  in 
extension  or  flexion.  The  electrical  reaction  of  the 
muscles  may  be  lost,  or  undergo  the  modification  of  de- 
generation. 

Death  frequently  occurs  after  only  a  few  days,  or 
the  patient  may  die  at  a  much  later  period,  apparently 
from  exhaustion.  Sometimes  recovery  is  complete  and 
perfect,  but  more  frequently  there  remain  partial  pa- 
ralyses and  atrophies.  A  chronic  leptomeningitis  last- 
ing for  months  or  years  is  said  sometimes  to  result  from 
the  acute  disease. 

DiAGT^osis.  — Jaccoud  says  :  "The  only  two  diseases 
of  the  spinal  cord  which  have  a  febrile  beginning  are 
acute  meningitis  and  acute  myelitis ;  now,  as  a  rule, 
these  two  inflammations  exist  together,  and  the  differ- 
ence in  diagnosis  is  only  a  matter  of  refinement  or  a 
question  of  relative  preponderance."  The  principal 
diagnostic  symptoms  of  spinal  meningitis  are  the  pain 
in  the  back  and  limbs,  the  hyperesthesia,  the  muscu- 
lar spasm,  and  contracture.  The  opisthotonus  might 
give  rise  to  the  suspicion  that  the  disease  is  tetanus ; 
but  in  that  there  is  much  less  fever,  less  pain,  except 
during  the  spasm,  and  little  or  no  cutaneous  hyperses- 
thesia;  at  the  beginning  there  is  trismus,  the  other 
spasms  are  more  violent,  and  the  reflex  irritability  is 
excessive.  If  there  is  recovery,  it  is,  as  a  rule,  more 
complete  in  tetanus  than  in  spinal  meningitis. 


INFLAMMATION'  OF  THE  PIA  MATER.  155 

Prognosis. — The  prognosis  is  said  by  Erb  to  be  "  in- 
fluenced for  the  worse  by  the  following  circumstances  : 
A  very  youthful  or  very  advanced  age ;  bad  constitu- 
tion, anaemia,  the  previous  occurrence  of  severe  disease, 
etc. ;  by  the  height  to  which  the  disease  ascends  in  the 
spine  toward  the  brain ;  by  early  symptoms  of  paraly- 
sis, signs  of  general  loss  of  strength,  high  fever,  con- 
tinually rising  temperature,  and  increasing  frequency 
of  pulse ;  great  diflBculty  in  breathing,  dysphagia,  se- 
vere cerebral  symptoms,  etc." 

The  disease  is  at  best  serious,  and  even  after  partial 
recovery  relapses  may  occur.  The  paralysis  and  atro- 
phy that  remain  may  disable  the  patient  for  the  rest  of 
his  life. 

Treatment. — The  sensitiveness  of  the  skin  may  be 
such  as  to  interfere  with  the  use  of  cups,  but,  if  possi- 
ble, dry  or  wet  cups  should  be  applied,  or  leeches  may 
be  used.  Ice-bags  should  be  kept  constantly  on  the 
spine.  After  the  first  acute  stage  has  passed,  blisters 
or  other  counter-irritation  may  be  applied  over  the  spinal 
column.  Most  European  authors  recommend  that  mer- 
cury be  used  by  inunction  or  internally.  Ergot  may  be 
given  in  large  doses  frequently  repeated.  Iodide  of 
potassium  can  be  used  after  the  earlier  stages  of  the 
disease.  The  pain  can  be  controlled  by  opiates,  which 
should  be  given  in  large  doses. 

It  is  scarcely  necessary  to  mention  that  quietness, 
rest  in  bed,  and  the  ordinary  hygienic  measures  be  ob- 
served. Decubitus  on  the  side  or  prone  is  the  best  posi- 
tion in  bed. 

The  paralyses  and  contractures  which  remain  after 
recovery  may  be  treated  by  electricity,  passive  motion, 
friction,  and  baths. 


CHAPTER  XL 

CHAT^GES   IIS^  BLOOD-SUPPLY. 

Mayer,  Sigmund,  Zur  Lehre  von  der  Anamie  des  Eiicken- 
marks.  Zeitschr.  f.  Heilk.,  iv,  1883,  p.  26. — Gull,  Paraplegia 
from  Obstruction  of  the  Abdominal  Aorta.  Guy^s  Hosp.  Reports, 
1858,  p.  311. 

SPINAL  HYPEREMIA. 

Congestion,  and  its  opposite,  ansemia,  of  the  spinal 
cord  and  its  membranes  have  been  too  frequently  men- 
tioned as  causes  of  symptoms  which  evidently  arise 
from  more  serious  lesions.  Clinically,  and  even  patho- 
logically, it  is  difficult  to  draw  the  line  of  separation 
between  congestion  and  inflammation.  It  is  almost  im- 
possible, also,  to  separate  these  lesions  of  the  meninges 
from  similar  lesions  of  the  cord  itself  ;  indeed,  the  spi- 
nal cord  is  always  more  or  less  implicated  when  the  pia 
mater  is  diseased.  While  it  is  probably  true  that  many 
slight  disturbances  of  health  are  ascribed  to  congestion 
when  there  is  really  inflammation,  yet  it  is  convenient 
to  speak  of  congestion,  and  describe  it  as  an  independ- 
ent disease. 

Etiology. — One  of  the  most  frequent  causes  is  cold, 
acting  upon  the  surface  of  the  body  when  the  patient 
is  heated  ;  if  dampness  is  combined  with  the  cold,  as 
when  the  patient's  clothing  is  wet  by  a  sudden  shower, 
or  when  the  patient,  overheated,  takes  a  cold  bath,  the 
influence  of  the  cold  is  much  increased. 

Suppression  of  the  menses,  or  hsemorrhoidal  bleed- 
ing, or  other  habitual  discharges,  may  act  as  causes  of 
congestion. 


SPmAL  HYPEREMIA.  I57 

Excessive  bodily  exertion,  especially  walking  and 
standing,  violent  sexual  excitement,  or  excess  of  coitus, 
may  have  the  same  effect. 

Mucli  of  the  backache,  and  some  of  the  pain  in  the 
limbs  found  at  the  commencement  of  febrile  diseases, 
are  probably  caused  by  spinal  hypereemia. 

Symptoms. — As  already  mentioned,  it  is  impossible 
to  separate  the  symptoms  caused  by  congestion  of  spi- 
nal meninges  fi'om  those  produced  by  congestion  of  the 
spinal  cord  itself.  The  following  description  may  serve 
for  both  conditions  : 

There  is  a  heavy,  dull  pain  in  the  small  of  the  back, 
or  higher,  sometimes  radiating  into  the  legs  with  sub- 
jective sensations  of  numbness  and  pricking ;  some- 
times a  girdle  sensation  is  felt ;  a  weakness  or  partial 
paralysis  of  the  legs  is  generally  present ;  rarely  slight 
spasms  or  twitches  of  muscles.  These  symptoms  ap- 
pear rather  suddenly,  and  may  be  aggravated  by  lying 
on  the  back.  Unless  inflammatory  changes  are  set  up, 
they  are  not  accompanied  with  febrile  action,  and  are 
usually  of  short  duration,  not  lasting  more  than  a  few 
days  or,  in  rare  cases,  weeks. 

DiAaNosis. — The  diagnosis  is  to  be  made  from  the 
slightness  of  the  symptoms  and  their  short  duration, 
and  the  absence  of  fever,  rather  than  from  any  pecul- 
iarity of  the  symptoms  themselves. 

Treatme2s"t. — Active  treatment,  such  as  bleeding 
and  purgatives,  have  been  recommended;  but,  instead  of 
general  bleeding,  wet  cups  or  leeches,  on  both  sides  of 
the  spine,  are  better :  dry  cups  may  be  used  with  ad- 
vantage in  the  same  place.  The  actual  cautery  may  be 
tried  with  reasonable  expectation  of  benefit.  Purga- 
tives may  be  of  use,  but,  if  pushed  far,  would  be  of  dis- 
advantage, from  the  necessity  of  disturbing  the  patient 
too  often.  Ice-bags  to  the  spine  may  be  used  to  advan- 
tage. Internally,  belladonna  and  ergot  have  been  rec- 
ommended. 

It  is  better  for  the  patient  to  be  kept  quiet,  confine- 


15$  DISEASES  OF  THE  SPINAL    CORD. 

ment  to  the  bed  being  preferred ;  the  causes  liable  to 
produce  congestion  should  be  avoided,  and  by  some  a 
position  upon  the  back  is  forbidden. 

SPINAL   ANAEMIA. 

In  animals,  experiment  has  shown  that  the  symp- 
toms of  ansemia  may  vary  according  as  it  is  suddenly 
produced,  or  is  brought  on  gradually.  If  all  the  blood 
is  shut  off  at  once  from  the  cord,  convulsions  occur  ;  if 
the  cord  is  gradually  deprived  of  blood,  there  is  only 
loss  of  function,  without  convulsion.  In  man  the  sud- 
den stoppage  never  occurs,  owing  to  the  free  anasto- 
moses. Sometimes,  in  aneurism  of  the  aorta,  ansemia 
of  the  cord  is  produced  by  occlusion  of  blood-vessels, 
and  serious  disturbance  of  function  may  result  there- 
from. In  general  ansemia  and  chlorosis,  in  cardiac  dis- 
ease, there  may  be  a  diminished  supply  of  blood  in  the 
cord. 

The  spinal  symptoms  are  not  sufficiently  well  de- 
fined to  form  a  positive  diagnosis  from  them  alone. 
There  is  simply  disturbed  function,  numbness,  motor 
weakness,  and  tremor,  without  fever.  There  is  a  con- 
dition, usually  called  spinal  irritation,  which  has  been 
referred  to  ansemia  of  the  spinal  cord,  but  without  suf- 
ficient reason.  The  diagnosis  must  be  made  chiefly 
from  symptoms  other  than  those  due  to  the  spinal  dis- 
turbance. 

The  treatment  should  be  directed  to  the  condition 
causing  the  ansemia ;  the  patient  should  be  kept  in  bed 
on  his  back  if  the  symptoms  are  at  all  serious ;  hot- 
water  bottles  may  be  applied  to  the  spine ;  strychnia 
has  been  recommended. 


CHAPTER  XII. 

SPIISTAL   HJEMOEEHAGE. 

Fox,  E.  L.,  Clinical  Lecture  on  Spinal  Haemorrhage.  Med. 
Times  and  Gaz.,  Aug.  26,  1876,  p.  219.— Goltdammer,  E.,  Ein 
Beitrag  zur  Lehre  von  der  Spinal- Apoplexie.  Virch.  Arch. ,  Ixvi, 
p.  1.— MacMunn,  C.  a.,  Notes  on  a  Case  of  Spinal  Apoplexy. 
Dublin  Jour,  of  Med.  Sci.,  March.  1,  1880,  p.  182.  — Eichorst,  H., 
Beitrag  zur  Lehre  von  der  Apoplexie  in  der  Riickenmarkssuhstanz. 
Charite-Annalen,  1876,  p.  192. — Hayem,  G-.,  Des  hemorrhagies 
intrarachidiennes.     Paris,  1872. 

MENINGEAL  n^MORRHAGE. 

^Etiology.  — Spinal  meningeal  hsemorrliage,  lisema- 
torrhacliis,  is  rather  a  rare  affection.  It  occurs  as  the 
result  of  injuries  and  falls,  or  in  consequence  of  over- 
taxing the  strength  ;  secondarily  as  following  aneurism, 
or  during  tetanus,  epilepsy,  or  some  acute  diseases, 
yellow,  typhoid,  or  pernicious  fever. 

Pathological  Anatomy.  —  The  blood  may  be 
poured  outside  the  dura  mater ;  it  may  fill  the  whole 
of  the  vertebral  canal,  but  is  more  frequently  spread 
over  the  posterior  surface  of  the  membrane  ;  again,  it 
may  be  limited  to  a  comparatively  small  extent.  The 
cervical  region  is  rather  more  frequently  the  seat  of 
the  haemorrhage.  The  condition  of  the  blood,  as  found 
at  the  autopsy,  depends  upon  the  length  of  time  that 
has  elapsed  between  the  attack  and  death. 

Intra-meningeal  haemorrhage,  where  the  blood  is 
effused  between  the  dura  mater  and  arachnoid,  is  less 
frequent  than  the  preceding.  Hayem  found  thirty- 
eight  cases  of  extra  meningeal  haemorrhage,  and  only 
eleven  of  this  variety. 


160  DISEASES  OF  TEE  SPINAL   COED. 

The  hsemorrhage  under  tlie  araclinoid  and  into  the 
pia  mater  is  still  more  rare,  Hayem  finding  only  eight 
cases. 

Many  times  the  blood  found  in  these  places  is 
poured  out  only  during  the  last  hours  of  life,  and  has 
no  effect  upon  the  primary  disease ;  this  is  especially 
true  where  the  haemorrhage  is  merely  slight  or  punc- 
tiform.  Where  there  is  considerable  blood,  however, 
the  spinal  cord  may  be  much  compressed. 

Symptoms. — Many  secondary  hsemorrhages  give  rise 
to  no  special  symptoms,  either  because  they  are  very 
slight,  or  because  the  primary  disease  masks  the  spe- 
cial symptoms  which  they  would  cause. 

The  symptoms  usually  appear  suddenly ;  there  is 
•first  severe  pain,  followed  almost  immediately  by  pa- 
ralysis. Occasionally  the  onset  is  more  gradual.  There 
are  two  classes  of  symptoms  which  must  be  recognized  : 
those  due  to  pressure  upon  the  cord,  and  changes  in 
its  structure  ;  those  due  to  irritation  of  the  membrane 
and  nerve-roots  by  the  foreign  body,  the  clot. 

The  symptoms  due  to  pressure  upon  the  cord  are 
primarily  more  or  less  complete  paraplegia,  affecting 
chiefly  motion,  but  also  giving  rise  to  sensations  of 
numbness  ;  after  the  commencement  of  the  attack  there 
may  be  pain  in  the  back,  or  it  may  be  absent.  Reflex 
action  may  be  exaggerated.  The  pressure  may  give 
rise  to  secondary  changes  in  the  cord,  myelitis  may  fol- 
low ;  the  paralysis  becomes  more  complete  and  perma- 
nent ;  sensation  may  be  more  seriously  implicated,  con- 
tractions may  appear,  and,  as  the  myelitis  advances, 
may  disappear  ;  the  muscles  may  undergo  atrophy. 

The  symptoms  due  to  irritation  by  blood-clot  and 
pressure  upon  the  nerve-roots  are  so  united  that  it  is 
scarcely  worth  while  to  separate  them.  These  are  pains 
radiating  in  the  course  of  the  nerves  and  others  referred 
to  the  periphery,  tingling  and  pricking  sensations,  more 
or  less  anaesthesia,  with  possibly  tenderness  to  touch  of 
the  parts  to  which  the  nerves  are  distributed ;  spas- 


MENINOEAL  HEMORRHAGE.  161 

modic  contractions,  generally  clonic,  sometimes  tonic ; 
subsequently  there  may  be  atrophy  and  diminished 
electric  excitability.  Disturbed  vaso-motor  action  may 
be  found  either  below  or  at  the  level  of  the  haemor- 
rhage. 

The  patient  may  entirely  recover,  but  more  fre- 
quently some  paralysis  and  atrophy  remain  perma- 
nently, accompanied,  perhaps,  with  contracture.  The 
electrical  reaction  undergoes  the  usual  change  in  atro- 
phied muscles. 

The  membranes  are  not  very  prone  to  secondary  in- 
flammation ;  fever  is  rarely  present ;  the  pulse  may  be 
weak  and  slow. 

The  symptoms  vary  somewhat  according  to  the  local- 
ity of  the  haemorrhage.  When  the  upper  part  of  the 
cord  is  affected,  the  pain  and  contraction  and  reflex 
phenomena  will  be  most  marked  in  the  upper  extremi- 
ties ;  oculo-pupillary  symptoms  will  be  observed,  and 
there  may  be  disturbance  of  respiration.  When  the 
seat  of  the  haemorrhage  is  lower,  the  above  symptoms 
will  be  absent,  and  the  sensory  and  motor  phenomena 
will  be  most  marked  in  the  back  and  legs ;  the  bladder 
and  rectum  may  be  affected,  priapism  may  give  annoy- 
ance, or  erection  may  be  less  frequent,  and  sexual  power 
diminished. 

DiAGi^osis. — The  chief  diagnostic  symptoms  are  the 
suddenness  of  the  attack,  the  signs  of  meningeal  irrita- 
tion, the  absence  of  cerebral  symptoms,  and  the  course 
of  the  disease  ;  sometimes  also  the  cause  will  aid  to  a 
diagnosis.  It  may  not  always  be  easy  to  determine  at 
first  whether  the  vertebrae  have  been  fractured  or  the 
cord  itself  injured  by  the  accident  which  has  given  rise 
to  the  symptoms.  Extreme  motor  paralysis,  especially 
if  reflex  action  is  diminished,  at  the  commencement  of 
the  disease,  and  serious  implication  of  the  sphincters, 
would  lead  to  an  inference  that  the  cord  itself  is  in- 
jured. 

A  careful  study  of  the  symptoms  would  probably 
11 


162  DISEASES  OF  TEE  SPINAL   CORD. 

be  sufficient  to  prevent  an  error  of  diagnosis  in  regard 
to  other  affections  of  the  cord  and  its  membranes. 

Teeatment. — The  most  important  indication  which 
should  be  strongly  insisted  upon  is  absolute  rest.  Erb 
says  upon  the  side  or  face ;  but  the  position  is  of  less 
importance  than  the  rest.  Leeches  or  wet  cups  should 
be  applied  along  the  back.  Strong  purgation  is  recom- 
mended, but  has  the  disadvantage  that  the  patient  must 
be  disturbed  too  much.  As  in  other  cases  of  haemor- 
rhage, large  doses  of  ergot  may  be  given,  if  the  case  is 
one  of  those  arising  spontaneously.  Pain  may  be  re- 
lieved by  opiates  and  anodynes.  Later,  iodide  of  potas- 
sium may  be  prescribed,  and  resulting  paralyses  can  be 
treated  by  electricity,  baths,  passive  motion,  and  mass- 
age. 

HEMORRHAGE  INTO  THE  SPINAL   CORD.— HEMATOMYELITIS. 

Etiology. — Haemorrhage  into  the  spinal  cord  is 
about  four  times  more  frequent  in  men  than  in  women  ; 
it  occurs  chiefly  in  early  adult  life — from  twenty  to 
thirty-five.  It  may  arise  in  the  course  of  inflammatory 
changes  in  the  spinal  cord  as  a  secondary  complication, 
or  be  caused  by  influences  which  favor  the  active  flow 
of  blood  to  the  cord ;  a  fall,  a  strain  in  lifting  heavy 
weights,  or  other  excessive  bodily  exertion,  may  be  a 
cause.  These  are  more  likely  to  prove  efficient  if  the 
blood-vessels  of  the  cord  are  diseased. 

Pathological  Anatomy. — Of  course,  the  primary 
change  in  the  cord  is  its  destruction  and  the  disasso- 
ciation  of  its  fibers  by  the  effused  blood.  The  clot 
undergoes  changes  similar  to  those  which  follow  cere- 
bral haemorrhage.  The  cord  undergoes  inflammatory 
changes  and  softening.  It  may  sometimes  be  difficult 
to  determine  whether  the  softening  is  caused  by  the 
haemorrhage  or  preceded  it.  Haemorrhage  is  most  fre- 
quent in  the  gray  substance.  The  muscles  and  nerves 
undergo  secondary  changes,  such  as  are  found  when  the 
spinal  nerve-centers  are  diseased. 


E^MORREAOE  INTO   THE  SPINAL   COED.        163 

The  meninges  are  almost  always  congested,  but  the 
inflammatory  changes  in  them  are  not  very  marked. 

When  the  patient  lives  long  enough,  secondary  de- 
generation, ascending  and  descending,  will  be  found  in 
the  cord. 

Symptoms. — The  symptoms  due  to  haemorrhage  into 
the  spinal  cord  may  be  preceded  by  obscure  symptoms 
of  discomfort  due  to  disturbances  of  circulation  or  nu- 
trition, which  precede  the  rupture  of  the  vessel,  and 
perhaps  depend  upon  the  changes  in  the  cord  which 
give  rise  to  the  haemorrhage.  These  changes  of  nutri- 
tion may  be  such  as  are  found  in  myelitis,  yet  the  symp- 
toms caused  thereby  may  not  attract  special  attention, 
or  may  be  the  result  of  an  acute  disease,  as  typhoid 
fever. 

When  a  blood-vessel  ruptures,  there  may  be  intense 
pain  in  the  back,  continuing  for  a  variable  length  of 
time,  followed  by  paralysis  of  motion  and  sensation  in 
the  parts  below.  The  occurrence  of  the  haemorrhage  is 
not  always  the  cause  of  such  tumultuous  symptoms  ;  it 
may  occur  during  sleep,  or  the  symptoms  may  be  de- 
veloped gradually  during  a  period  of  several  hours  or, 
in  rare  instances,  some  days.  In  the  latter  case  it  is 
more  probable  that  a  myelitis  has  preceded  the  haemor- 
rhage. 

However  it  may  arise,  the  chief  symptoms  are  finally 
very  similar.  As  the  seat  of  the  effusion  is  generally 
the  central  gray  matter,  sensation  is  more  or  less  pro- 
foundly affected,  and  it  may  be  entirely  abolished  ;  mo- 
tion is  restricted,  and  generally  lost  in  the  parts  below 
the  lesion.  At  the  beginning  there  may  be  a  certain 
amount  of  tetanic  rigidity  or  spasmodic  twitching,  but 
this  is  of  short  duration,  and  the  limbs  are  soon  relaxed 
in  paralysis.  If  the  lesion  is  not  so  low  as  to  implicate 
the  lumbar  nerves,  the  reflex  irritability  is  increased,  as 
in  other  cases  where  the  lower  part  of  the  cord  is  sev- 
ered from  communication  with  the  brain,  though  im- 
mediately after  the  shock  of  the  haemorrhage  the  reflex 


164  DISEASES  OF  TEE  SPINAL  CORD. 

functions  may  be  temporarily  suspended.  Conscious- 
ness and  intelligence  are  not  affected. 

At  tlie  very  onset,  if  there  has  been  no  previous  ele- 
vation of  temperature  due  to  other  disease,  there  is  no 
fever;  soon  inflammatory  changes  commence  around 
the  clot,  and  then  the  temperature  may  rise  ;  as  yet  few 
observations  of  these  changes  have  been  made.  The 
temperature  of  the  paralyzed  limbs  was  noticed  by 
Levier  to  be  0'2°  to  1'9°  C.  higher  than  the  arms,  the 
thermometer  being  in  the  fold  formed  by  bending  the 
knee  and  in  the  axilla. 

As  the  secondary  changes  extend,  the  symptoms  be- 
come more  decided ;  if  there  was  only  a  partial  loss  of 
sensation,  the  anaesthesia  becomes  complete ;  there  is 
entire  loss  of  motion  instead  of  partial  paralysis.  The 
muscles  which  arise  from  the  portion  of  the  cord  de- 
stroyed undergo  atrophy  and  show  the  reaction  of  de- 
generation. As  secondary  degeneration  extends  below 
the  seat  of  the  lesion,  the  symptoms  due  to  affection  of 
-the  lateral  columns  appear. 

The  bladder  and  rectum  are  paralyzed,  the  urine 
may  be  very  quickly  changed  in  character,  may  contain 
blood,  may  be  intensely  acid,  or  may  soon  become  alka- 
line. Some  of  these  changes  in  the  urine  are  dependent 
upon  disturbed  innervation  of  the  kidneys  and  not  upon 
cystitis,  which  may  later  cause  much  trouble. 

Bed-sores  sometimes  form  with  amazing  rapidity, 
and  become  enormous  in  size. 

The  symptoms  will  vary  somewhat,  in  different  cases, 
according  to  the  height  at  which  the  haemorrhage  oc- 
curs and  the  amount  of  blood  poured  out.  In  view  of 
the  physiology  of  the  cord,  it  will  not  be  difficult  to 
locate  approximately  the  upper  limit  of  the  lesion  and, 
somewhat  roughly,  its  lower  limit. 

Diagnosis. — Haemorrhage  into  the  substance  of  the 
cord  can  be  distinguished  from  meningeal  haemorrhage 
by  the  more  complete  and  suddenly  occurring  paraly- 
sis of  both  motion  and  sensation,  by  the  absence  of 


HEMORRHAGE  INTO   THE  SPINAL   CORD.        165 

signs  of  great  irritation,  and  by  the  rapid  appearance 
of  bed-sores.  The  diagnosis  may  be  easier  in  cases 
where  there  has  been  a  preceding  disease  of  the  spinal 
cord. 

In  rare  cases  the  haemorrhage  may  be  confined  to 
one  side  of  the  spinal  cord  ;  then  the  paralysis  of  mo- 
tion will  be  hemiplegic.  The  fact  that  there  is  no  loss 
of  consciousness,  and  that  sensation  is  affected  on  the 
side  opposite  the  motor  disturbance,  will  prevent  such 
a  lesion  from  being  mistaken  for  cerebral  haemor- 
rhage. 

From  myelitis  arising  spontaneously  the  diagnosis 
must  be  made  by  considering  the  causes,  the  mode  of 
onset,  and  the  progress  of  the  symptoms  ;  a  careful  con- 
sideration of  these  points  will  probably  prevent  an  error 
of  diagnosis,  unless  the  myelitis  is  developed  with  un- 
usual rapidity.  MacMunn  mentions  intensely  acid 
urine  as  peculiar  to  haematomyelia,  distinguishing  it 
from  myelitis. 

From  acute  anterior  poliomyelitis  the  diagnosis  may 
be  made  by  the  fact  that  in  this  there  is  no  disturbance 
of  sensation,  that  the  bladder  and  rectum  are  not  para- 
lyzed, bed-sores  do  not  form,  and  the  fever,  if  any,  is 
at  the  beginning,  whereas  in  hsematomyelia  the  fever 
appears  later,  unless  the  haemorrhage  is  secondary.  In 
the  former  also  there  is  a  tendency  for  some  muscles  to 
regain  their  function  ;  in  the  latter  the  paralysis  tends 
to  increase. 

PEOGisrosis. — If  a  large  amount  of  blood  is  effused, 
the  symptoms  will  be  correspondingly  severe,  and  the 
prognosis  must  be  serious ;  if  only  a  small  amount  is 
effused,  the  symptoms  will  be  proportionately  light, 
and  recovery,  or  partial  recovery,  may  occur.  If  the 
haemorrhage  is  in  the  cervical  region,  death  is  more 
likely  to  follow. 

If  the  patient  survives  the  first  attack,  he  may  die 
exhausted  by  cystitis  or  bed-sores.  If  he  survives  long 
enough,  the  paralyzed  muscles  may  undergo  atrophy, 


166  DISEASES  OF  TEE  SPINAL   COED. 

wMcli  may  persist  during  tlie  rest  of  life,  accompanied 
possibly  with  contracture. 

Treatment. — It  is  quite  unlikely  that  any  measures 
directed  to  stopping  the  bleeding  can  be  applied  in  sea- 
son to  be  of  any  advantage.  To  prevent  further  dam- 
age by  a  renewal  of  the  haemorrhage  or  by  secondiary 
myelitis,  the  patient  should  be  kept  quiet,  and  cold  ap- 
plied to  the  back  continuously.  Local  blood-letting 
may  be  resorted  to,  ergot  may  be  given  internally,  pain 
should  be  relieved,  the  bowels  and  bladder  should  be 
sedulously  cared  for,  the  danger  of  bed-sores  should  be 
kept  in  mind,  and  subsequent  paralyses  and  atrophies 
should  be  combated  by  the  usual  means. 


CHAPTER  XIII. 

COMPEESSIOJSr   OF   THE   SPINAL   COED. 

Kadner,  Zur  Casuistik  der  Ruckenmarkscompression.  Arch, 
der  Heilkunde,  1876,  p.  481. — Kahler,  O.,  Ueber  die  Veranderun- 
gen  welche  sich  im  Ruckenmarke  in  Folge  einer  geringgradi- 
gen  Compression  entwickeln.  Zeitschr.  f.  Heilk.,  iii,  1883,  p. 
187.— Humphrey  Laurence,  Slow  Compression  of  the  Spinal 
Cord.  Lancet,  Jan.  5,  1884,  p.  14. — Sayre,  Lewis  A.,  Spinal 
Disease  and  Curvature.  London,  1877. — Marsh,  H.,  On  the  Di- 
agnosis of  Caries  of  the  Spine  in  the  Stage  preceding  Angular 
Curvature.  Brit.  Med.  Jour.,  June  11,  1881,  p.  913. — ^RussEL, 
William,  The  Early  Diagnosis  of  Spinal  Caries.  Brit.  Med.  Jour., 
Nov.  13,  1881,  p.  771. 

SLOW  COMPRESSION. 

Sudden  compression,  in  so  far  as  it  is  not  surgical, 
has  been  mentioned  in  connection  with  spinal  menin- 
geal lisemorrliage. 

Etiology. — Slow  compression  is  caused  by  caries 
of  the  vertebrse,  by  thickening  of  the  membranes 
(pachymeningitis),  by  cancer  of  the  vertebrae,  or  by 
tumors  within  the  vertebral  canal. 

Pathological  Anatomy. — The  changes  found  in 
the  cord  are  the  same  as  those  found  in  myelitis ; 
sometimes  the  destruction  is  complete,  the  cord  being 
softened ;  sometimes  it  is  pressed  out  of  shape,  and  has 
undergone  chronic  interstitial  changes,  which  give  it 
a  consistency  firmer  than  natural.  Secondary  degen- 
erations are  found  above  the  point  of  compression  in 
the  posterior  columns,  sometimes  in  the  cerebellar  tracts, 
below  in  the  anterior  and  lateral  pjramidal  columns. 

The  membranes  are  more  or  less  inflamed,  thickened, 


168  DISEASES  OF  THE  SPINAL   CORD. 

and  covered  perhaps  witli  pus  ;  especially  in  caries  the 
dura  mater  may  be  pressed  inward  by  collections  of 
pus  so  as  to  press  upon  the  cord.  It  is  rare  to  find  the 
vertebral  canal  so  narrowed  by  displacement  of  the  ver- 
tebrae that  the  bones  press  upon  the  cord.  If  there  is 
no  pus  formed  behind  the  dura  mater,  and  if  myelitis 
is  not  set  up,  the  bones  may  soften  and  fall  together, 
so  as  to  form  a  very  marked  curvature,  with  almost  no 
symptoms  referable  to  the  cord. 

If  the  membranes  are  inflamed  and  thickened,  the 
nerves,  as  they  pass  out  of  the  vertebral  canal,  sur- 
rounded by  the  diseased  membrane,  are  also  inflamed. 

Symptoms. — The  symptoms  will  vary  according  to 
the  level  of  the  disease  causing  the  compression ;  but 
there  are  symptoms  common  to  all  localities. 
.,  The  earlier  symptoms  are  dependent  upon  irritation 
of  the  nerves  or  the  membranes ;  subsequent  symp- 
toms depend  also  upon  disease  of  the  cord. 

Pain  generally  first  attracts  attention.  The  pains 
due  to  irritation  of  the  nerve-roots  are  of  a  shooting, 
darting  character,  referred  to  the  peripheral  distribu- 
tion of  the  affected  nerves.  If  the  upper  cervical 
nerves  are  thus  irritated,  the  pain  may  be  felt  over  the 
back  of  the  head,  the  side  of  the  face  near  the  angle  of 
the  jaw,  or  over  the  neck  and  shoulders.  When  the 
cervical  or  lumbar  nerves  are  affected,  the  pain  will  be 
felt  in  the  limbs.  If  the  dorsal  nerves,  the  pain  will  be 
felt  in  the  chest  or  upper  part  of  the  abdomen,  usually 
near  the  median  line,  sometimes  a  little  on  one  side. 
It  may  simulate  angina  pectoris,  or  the  stomach-ache, 
or  colic,  according  to  location.  Instead  of  pain,  there 
may  be  only  a  sense  of  discomfort  or  irritation,  as 
itching.  Motions  which  change  the  relation  of  the  ver- 
tebrae to  one  another,  as  bending,  or  twisting  the  trunk, 
may  increase  the  pain  very  much,  this  is  especially  so 
when  the  vertebrae  are  diseased.  Jars,  as  in  riding,  or 
percussion  on  the  shoulders,  will  increase  the  pain 
when  the  vertebrae  are  diseased. 


SLOW  COMPEESSION.  169 

Hypereestliesia  maybe  noticed  during  or  immedi- 
ately after  the  attacks  of  pain.  This  hypersesthesia 
may  also  be  noticed  between  and  independently  of  the 
attacks. 

Common  sensation  may  be  very  much  diminished. 

These  disturbances  of  sensation  depend  upon  le- 
sion of  the  nerves,  and  belong  to  the  earlier  symptoms. 
Later,  the  backache  may  be  more  marked  ;  there  appear 
pains  depending  upon  lesion  of  the  cord,  less  lancinat- 
ing in  character,  which  resemble  those  found  in  myeli- 
tis from  other  causes.  These  pains  are  found  in  the 
parts  supplied  with  nerves  arising  from  the  cord  below 
the  seat  of  compression  ;  they  consist  in  sensations  of 
numbness,  pricking  or  tingling,  a  sleepy  sensation,  as 
though  the  parts  were  asleep,  or  an  aching.  Ordinary 
sensation  may  be  diminished  or  retarded.  Finally, 
there  may  be  complete  anaesthesia  below  the  lesion. 

In  the  beginning,  even  before  there  is  any  pain, 
there  may  be  motor  symptoms,  which  are  frequently 
overlooked.  There  is  first  a  sense  of  fatigue  ;  the  pa- 
tient dislikes  to  exert  himself,  and,  if  a  child,  will  ex- 
change his  active  plays  for  more  quiet  sedentary  ones. 

When  carefully  observed,  he  will  be  noticed  to  have 
a  peculiar  stiff  gait,  and,  in  stooping,  the  back  will  be 
kept  rigid  and  the  knees  will  be  bent  instead.  This 
is  most  marked  in  caries  and  other  diseases  of  the  ver- 
tebrae. If  the  cervical  vertebrae  are  affected,  the  pa- 
tient will  steady  his  head  with  his  hands  when  lying 
down  or  rising.  Passive  motion  will  be  resisted,  and, 
if  the  head  or  body  is  moved  forcibly,  pain  will  be  ex- 
cited. 

The  muscular  weakness  gradually  increases  until 
the  patient  is  no  longer  able  to  support  himself  on  his 
legs.     Finally  there  is  entire  motor  paralysis. 

When  the  disease  is  above  the  lumbar  enlargement, 
the  cutaneous  reflexes  are  often  exaggerated,  so  that 
severe  contractions  may  follow  even  slight  irritations. 
Tendon  reflex  may  be  increased,  and  ankle  clonus  may 


170  DISEASES  OF  TEE  SPINAL   CORD. 

be  excited.  When  paralysis  is  complete,  there  is  usu- 
ally contraction  of  the  legs  upon  the  thighs,  and  of  the 
thighs  upon  the  pelvis.  This  may  be  so  strong  that 
it  can  not  be  overcome  by  any  reasonable  amount  of 
force. 

General  epileptiform  convulsions  occasionally  occur 
even  when  the  disease  is  situated  in  the  lower  part  of 
the  cord. 

The  muscles  may  undergo  atrophy.  There  may  be 
herpes  zoster;  bed-sores  may  form.  Disease  of  the 
joints,  spinal  arthritis,  has  been  seen  in  vertebral  caries. 

In  caries  and  cancer  of  the  vertebrae,  these  symp- 
toms may  be  independent  of  any  deformity ;  neither  is 
there  tenderness  on  pressure  over  the  spinous  processes 
until  after  the  earlier  stages. 

When  the  cervical  or  upper  dorsal  part  of  the  cord 
is  affected,  the  pupil  may  be  widely  dilated  or  con- 
tracted;  generally  the  latter.  The  face  and  eyes  may 
be  more  or  less  congested  from  paralysis  of  the  vaso- 
motor nerves. 

The  temperature  of  the  whole  body  may  be  influ- 
enced by  the  disease  in  the  cervical  region.  The  heart's 
action  may  be  slow  ;  respiration  may  be  disturbed. 

Diagnosis. — It  is  important  to  form  a  correct  diag- 
nosis early  in  vertebral  caries,  especially  as  the  longer 
the  delay  the  more  likelihood  there  is  of  deformity. 

The  earliest  symptoms  have  already  been  mentioned, 
and  whenever  they  are  met  a  careful  examination  should 
be  made  of  all  the  circumstances  attending  their  origin, 
cause,  and  development.  The  physician  must  disabuse 
himself  of  the  idea  that  in  caries  of  the  vertebrae  there 
is  necessarily  deformity  or  tenderness  to  pressure  over 
the  spine  ;  there  may  not  be  tenderness  even  to  direct 
percussion  in  the  early  stage,  but  percussion  on  the 
shoulders  may  give  rise  to  pain  in  the  diseased  parts. 

Acute  spinal  meningitis  is  attended  with  pain  in 
the  back  and  limbs,  but  it  commences  suddenly  vsdth 
fever,  and  is  evidently  a  severe  affection. 


SLOW  COMPRESSIOK  171 

The  pain  attending  spinal  irritation  may  lead  to  a 
suspicion  of  compression  of  the  cord,  and  it  may  not 
always  be  easy  at  once  to  say  there  is  no  disease  of  the 
bones.  The  attending  symptoms  will  generally  clear 
up  the  diagnosis.  There  is  less  of  the  peculiar  stiffness 
of  gait  and  carriage,  the  pain  is  not  felt  so  acutely  at 
the  peripheral  end  of  the  nerves,  the  pain  is  not  in- 
creased by  percussion  on  the  head  or  shoulders  to  the 
same  degree,  and  in  spinal  irritation  there  is  much 
greater  tenderness  on  pressure  over  the  spinous  pro- 
cesses than  is  ever  found  in  compression  at  so  early  a 
date.  The  age  of  the  patient,  the  history  of  the  origin 
of  the  affection,  and  the  past  history  of  the  patient, 
may  aid  in  diagnosis,  as  will  also  the  hysterical  physi- 
ognomy which  is  often  to  be  noticed  in  the  less  serious 
affection. 

The  diagnosis  between  the  different  causes  of  com- 
pression of  the  spinal  cord  must  often  be  made  from 
symptoms  other  than  those  belonging  to  the  spinal  dis- 
ease itself.  Aneurisms  of  the  aorta  may  erode  the  ver- 
tebrae and  press  on  the  cord  ;  there  is  usually  very  lit- 
tle difSculty  in  recognizing  the  nature  of  this  affection. 

Cancer  of  the  vertebrae  may  give  rise  to  very  similar 
symptoms  with  caries.  When  the  pain,  shooting  along 
the  course  of  the  nerves,  is  extremely  severe,  without 
intermission,  apparently  independent  of  movement,  the 
probability  is  that  it  is  caused  by  cancer  ;  yet,  early  in 
the  disease,  the  pain  may  be  much  less  severe,  or  may 
be  scarcely  noticeable.  The  spinal  cord  itself  is  less 
frequently  implicated  in  cancer,  and  there  is  not  the 
formation  of  pus  which  is  seen  when  the  bodies  of  the 
vertebrae  are  carious. 

The  age  of  the  patient  may  aid  in  diagnosis,  caries 
being  most  frequent  in  early  childhood,  an  age  when 
cancer  is  very  rare. 

The  presence  of  cancer  elsewhere,  and  the  cancerous 
cachexia,  would  aid  materially  in  diagnosis. 

A  tumor  within  the  vertebral  canal  may  give  rise  to 


172       DISEASES  OF  TEE  SPIFAL   CORD. 

symptoms  closely  resembling  those  of  caries.  The 
pain,  central  and  peripheral,  may  be  the  same;  the 
paralysis  may  be  similar.  There  is  less  marked  stiff- 
ness in  gait,  less  difficulty  in  bending  the  spine ;  per- 
cussion of  the  shoulders  is  less  painful.  The  age  of 
the  patient,  and  his  previous  history,  will  aid  the  diag- 
nosis. If  a  slight  deformity  is  discovered,  tumor  would 
be  excluded. 

Peogistosis.  — The  prognosis  of  caries  is  not  very  un- 
favorable. If  there  is  deformity,  it  can  not  be  reme- 
died, but  even  extreme  paralysis  may  disappear,  and 
the  patient  recover.  If  muscles  have  undergone  atro- 
phy, they  may  be  partially  restored.  The  nearer  the 
disease  is  to  the  medulla,  the  more  serious  is  the  con^ 
dition,  and  the  greater  danger  of  sudden  death. 

The  prognosis  in  cancer  of  the  vertebrae  and  tumors, 
or  aneurisms  penetrating  the  spinal  canal,  is  necessarily 
unfavorable. 

Treatment. — Of  internal  remedies,  those  which 
will  restore  the  general  health  when  the  constitution  is 
broken  down  are  of  most  value. 

In  caries  the  only  hope  of  recovery  is  to  be  found  in 
ankylosis  of  the  diseased  vertebrae.  As  the  inflam- 
mation around  the  diseased  bones  is  increased  by  their 
pressure  one  upon  the  other,  and  by  the  friction  of  dis- 
eased surfaces  against  one  another,  it  is  necessary,  in 
order  to  diminish  that  influence  as  much  as  possible,  to 
keep  the  diseased  parts  quiet  and  relieve  the  bodies  of 
the  vertebrae  of  pressure.  The  means  of  accomplish- 
ing this  need  not  be  mentioned  here ;  it  belongs  rather 
to  surgery.  The  treatment  of  cold  abscesses  also  be- 
longs to  surgery. 

To  relieve  the  paralysis  in  caries  of  the  spine,  the  act- 
ual cautery,  applied  by  the  side  of  the  spine,  has  been 
used  with  excellent  results.  This  can  not  well  be  ap- 
plied while  the  patient  is  wearing  a  jacket,  except  as 
that  is  removed  for  a  day  or  two,  and  this  is  rarely 
advisable. 


SPINAL  TUMORS.  173 

Electricity,  faradic  or  galvanic,  to  stimulate  para- 
lyzed muscles,  should  be  used. 

The  nutrition  of  the  patient  should  be  maintained 
as  well  as  possible ;  cod-liver  oil  and  cream  are  es^De- 
cially  indicated  in  strumous  subjects.  The  patient 
should  be  placed  in  the  best  hygienic  conditions  possi- 
ble. 

SPINAL  TUMORS. 

The  more  common  varieties  of  tumors  found  in  the 
vertebral  canal  are  cancer,  generally  arising  from  the 
vertebrae ;  sarcoma  and  fibro-sarcoma,  and  osteoma ; 
parasites,  echinococcus,  or  cysticercus,  are  more  fre- 
quently connected  with  the  membranes ;  tubercular 
and  syphilitic  tumors  may  be  either  connected  with 
the  membranes  or  be  seated  in  the  substance  of  the 
cord  itself ;  gliomata  are  found  in  the  substance  of  the 
cord. 

From  pressure  or  from  secondary  inflammatory 
changes  the  spinal  cord  undergoes  a  degenerative  pro- 
cess usually  leading  to  softening;  sometimes,  how- 
ever, there  is  simply  atrophy  of  the  nerve-elements, 
and  the  cord  may  acquire  a  somewhat  firmer  con- 
sistency than  normal.  When  the  tumor  is  in  the  sub- 
stance of  the  cord,  its  center  may  undergo  degen- 
eration, and,  by  a  process  of  softening,  a  cavity  be 
formed.  Many  of  the  cavities  found  in  the  spinal 
cord  originate  in  this  way ;  gliomata  are  most  liable 
to  this  change. 

Etiology. — Except  in  cases  of  tubercle,  syphilis, 
and  cancer,  we  know  very  little  about  the  causes  of 
spinal  tumors,  and  even  in  regard  to  these  varieties  we 
can  only  say  that  the  germs  are  conveyed  by  lymphat- 
ics or  blood-vessels  to  their  new  seat  of  growth,  or  that 
a  corresponding  diathesis  causes  their  growth.  Some- 
times it  would  seem  that  an  injury,  as  a  fall  or  a  blow 
upon  the  back,  has  served  as  a  starting-point  for  the 
^owth  of  tumors. 


174  DISEASES  OF  THE  SPINAL   CORD. 

EXTRA-MEDULLARY  (MENINGEAL)  TUMORS. 

Symptoms. — The  symptoms  are  almost  the  same  as 
those  found  in  connection  with  caries  of  the  vertebrae. 
There  are  the  symptoms  due  to  irritation  of  nerve-roots 
and  those  depending  upon  compression  of  the  cord. 
The  symptoms  may  be  unilateral  or  bilateral,  according 
to  the  locality  of  the  tumor.  The  growth  of  the  tumor 
is  usually  very  slow,  and  the  development  of  the  symp- 
toms is  correspondingly  slow,  the  slighter  early  symp- 
toms sometimes  continuing  for  years  before  a  definite 
diagnosis  can  be  made.  Pain  at  the  seat  of  the  tumor, 
of  a  dull,  pressing  nature,  may  be  increased  by  motions 
of  the  body,  but  is  felt  at  other  times  also.  Percus- 
sion over  the  spinous  processes  may  increase  the  pain 
or  give  it  for  a  moment  a  more  lancinating  character. 
The  nerves  arising  from  the  level  of  the  tumor  may 
be  implicated ;  then  the  pain  will  be  felt  at  the  periph- 
ery, as  in  caries.  Atrophy  of  the  muscles  to  which 
these  nerves  are  distributed  with  the  reaction  of  de- 
generation will  indicate  the  serious  change  which  the 
tumor  may  cause  in  the  nerve-roots.  Other  trophic 
lesions,  as  herpes  and  bed-sores,  may  make  their  ap- 
pearance. 

Paralysis  finally  sets  in  with  increased  reflex  irrita- 
bility, spasms,  or  contractures.  A  careful  study  of  the 
nerves  affected,  as  shown  by  the  distribution  of  the 
paralysis  or  the  anaesthesia,  will  indicate  the  level  of 
the  disease,  and  show  also  whether  the  cord  is  affected, 
or  only  the  nerves  of  the  chorda  equina. 

Diagnosis. — No  symptoms  or  combination  of  symp- 
toms are  sufficient  for  forming  a  positive  diagnosis ; 
it  is  only  by  a  careful  examination  of  all  the  circum- 
stances that  other  affections  can  be  excluded  and  the 
probability  of  a  tumor  be  recognized.  Caries  and  can- 
cer of  the  vertebrae  most  closely  resemble  tumor  in 
their  symptoms. 


INTEA-MEDULLARY  SPINAL   TUMORS.  175 

INTRA-MEDULLARY   SPINAL   TUMORS. 

The  tumors  which  have  been  found  in  the  substance 
of  the  cord  are  gliomatous,  tubercular,  syphilitic,  or 
sarcomatous.  They  are  very  rare.  Their  growth  is 
often  slow,  but  they  give  rise  to  symptoms  sooner  than 
the  extra-medullary  growth.  There  is  no  necessity  for 
describing  these  growths,  as  they  are  like  others  found 
elsewhere. 

Symptoms. — The  symptoms  are  very  much  like  those 
belonging  to  acute  or  chronic  myelitis,  including  dis- 
turbance of  sensation  and  motion,  atrophy  of  muscles, 
and  local  trophic  changes.  Sometimes  the  symptoms 
much  more  closely  resemble  those  due  to  meningeal 
tumor,  pain,  both  local  and  peripheral,  and  increased 
reflex  irritability,  being  prominent.  The  symptoms 
must  vary  with  the  seat,  rate  of  growth,  and  conse- 
quent size  of  the  tumor.  There  are  no  symptoms  diag- 
nostic of  spinal  tumors  by  which  one  can  be  guided  to 
a  certain  conclusion. 

Peognosis. — The  prognosis  is  necessarily  unfavor- 
able. A  syphilitic  gummata  may  theoretically  be  ab- 
sorbed, but  it  would  then  be  impossible  to  satisfy  a 
skeptic  that  the  diagnosis  was  correct. 

Treatment. — Except  the  use  of  iodide  of  potassium 
or  some  equivalent  preparation,  there  is  nothing  to  be 
done  further  than  to  care  for  the  patient's  comfort  and 
look  after  any  complications  which  may  arise. 


CHAPTER  XIV. 

STEINGOMTELIA. —  FOEMATIOlSr    OF    CAVITIES. —  HYDEO- 

MYELUS. 

ScHUPPEL,  0.,  Ueber  Hydromyelus,  ArcMv  der  HeilJc.,  vi, 
1865,  p.  289. — Westphal,  Ueber  einen  Fall  von  Hohlen-  und  Ge- 
schwulstbildung  im  Etlckenmarke  mit  Erkrankung  des  verlanger- 
ten  Marks  und  einzelner  Hirnnerven.  Arch.  f.  Psych,  und  Ner- 
venkr.,  v,  1875,  p.  90.— Simon.  Ibid.,  p.  108.— Schultze,  F.  Ibid., 
viii,  1878,  p.  367.— Eickholt,  August.  Ibid.,  x,  1880,  p.  695.— 
Westphal,  C,  A  Contribution  to  the  Study  of  Syringomyelia 
(Hydromyelia).     Brain,  July,  1883,  p.  145. 

Occasionally  cavities  are  found  in  the  spinal  cord, 
wMch.  are  clearly  the  result  of  an  abnormal  develop- 
ment of  the  central  canal ;  this  condition  may  be  con- 
genital. The  canal  may  be  dilated  through  only  a  short 
tract,  or  through  nearly  its  vs^hole  length.  Sometimes 
the  canal  is  double,  or  diverticula  may  be  found  which 
branch  from  the  canal  and  can  be  followed  for  a  few 
millimetres,  running  near  the  central  canal.  As  an- 
other variety  of  malformation,  cases  are  seen  where  the 
central  canal  has  not  been  closed.  The  central  canal 
may  be  secondarily  dilated,  when  by  pressure  it  is 
closed  above  or  below  the  dilated  portion,  or  it  may  be 
found  dilated  in  connection  with  certain  diseases,  as 
cerebro-spinal  meningitis,  or  occasionally  in  cases  of 
chronic  myelitis. 

In  all  these  instances  in  which  the  central  canal  is 
enlarged,  the  walls  of  the  cavity  will  be  lined  with  epi- 
thelium, and  it  will  be  situated  the  same  as  the  normal 
canal  with  reference  to  other  parts  of  the  cord. 


FORMATION  OF  CAVITIES.  177 

In  a  large  number  of  cases,  however,  the  cavity  is 
pathological  and  is  independent  of  the  central  canal, 
which  may  be  seen  Just  in  front  or  to  one  side  of  the 
abnonnal  cavity  ;  the  central  canal  is  usually  distorted, 
and  it  may  be  so  flattened  as  to  be  scarcely  recogniz- 
able, only  a  narrow  line  of  epithelial  cells  showing  its 
location.  An  abnormal  cavity,  according  to  Simon, 
may  be  lined  with  cylindrical  epithelium,  as  when  one 
is  formed  in  a  glioma.  He  thinks  position  is  most  im- 
portant for  diagnosis. 

The  cavity  is  most  frequently  found  in  the  posterior 
part  of  the  cord,  it  may  be  formed  at  the  expense  of 
the  gray  commissure  or  the  posterior  cornua,  may  take 
part  of  the  space  occupied  by  the  posterior  columns, 
or  it  may  be  in  the  anterior  cornua.  The  gray  sub- 
stance is  much  the  more  frequently  affected.  The  cav- 
ity may  be  single  or  double,  may  be  a  few  millimetres 
in  length  or  may  extend  the  whole  length  of  the  cord, 
and  may  be  very  small  or  as  large  as  the  finger. 

Etiology. — The  cause  of  the  formation  of  a  cavity 
is  not  the  same  in  every  case.  A  haemorrhage  into  the 
cord  may  leave  a  cavity  after  the  clot  has  been  absorbed ; 
the  plugging  of  blood-vessels,  miich  more  rare,  may  be 
the  cause.  Several  cases  have  been  reported  in  which 
it  has  seemed  that  a  glioma  formed  in  the  central  gray 
substance,  and  that  the  center  of  this  has  softened  and 
been  absorbed.  Hallopeau  has  suggested  that  an  in- 
flammation about  the  central  canal  may  give  rise  to  an 
enlargement  of  that  canal,  or  a  central  myelitis  may 
lead  to  the  formation  of  a  canal  outside  the  central  canal. 

Eichorst  and  Naunyn  found  that,  after  crushing 
the  cord  in  young  animals,  a  cavity  was  formed  above 
the  poiQt  crushed.  They  referred  this  to  the  dilatation 
of  a  lymph-canal  which  they  suppose  runs  at  the  bot- 
tom of  the  posterior  fissure.  Westphal  accepts  this  as 
a  possible  explanation  of  the  formation  of  some  cavi- 
ties. 

There  are  no  special  symptoms  caused  by  cavities, 

12 


178  DISEASES  OF  THE  SPINAL   COBD. 

SO  far  as  is  known.  Those  symptoms  whicli  have  been 
found  in  cases  of  syringomyelia  were  sucli  as  were  due 
to  the  disease  which  gave  rise  to  the  cavity. 

There  is  nothing  to  be  said  as  to  treatment  other 
than  what  belongs  to  the  primary  disease,  if  any,  which 
causes  the  formation  of  the  cavity. 


CHAPTER  XY. 

MYELITIS. 

Frommann,  C,  Untersuchungen  iiber  die  normale  und  patholo- 
gische  Anatomie  des  Eiickenmarks.  Jena,  1864,  1867. — DUJAR- 
din-Beaumetz,  G.,  De  la  my  elite  aigue.  Paris,  1872. — Anderson, 
M'C,  On  a  Case  of  Myelitis.  Edin.  Med.  Jour.,  Aug.,  1881,  p. 
97. — Hallopeau,  H.,  Etude  sur  les  my  elite  chroniques  difiPuses. 
Arch.  gen.  de  med.,  Sept.,  1871. — Zunker,  Beitrage  zur  Myelitis 
Chronica.     Charite  Annalen,  v,  1880,  p.  260. 

Myelitis  is  an  inflammation  of  the  spinal  cord,  and 
may  be  acute  or  chronic ;  the  gray  or  the  white  sub- 
stance may  be  affected,  the  nervous  tissues,  cells,  and 
fibers  may  be  chiefly  and  primarily  affected,  or  the 
principal  change  may  be  found  in  the  interstitial  tis- 
sue, the  nervous  structures  suffering  secondarily. 

ACUTE   MYELITIS. 

Etiology. — Acute  myelitis  is  most  frequently 
caused  by  exposure  to  wet  and  cold ;  these  two  influ- 
ences are  most  likely  to  give  rise  to  inflammation  of  the 
spinal  cord  when  the  legs,  more  especially  the  thighs, 
and  the  back  are  thus  exposed  for  a  considerable  length 
of  time,  as  by  sleeping  upon  the  damp  ground  in  cool 
weather,  or  riding  in  a  carriage  or  on  horse-back  in  a 
storm,  with  insufficient  protection.  The  influence  of 
the  above  causes  is  very  much  increased  if  there  has 
been  severe  or  prolonged  bodily  exertion  at  the  time 
of  the  exposure  or  just  preceding  it.  Excessive  bodily 
exertions  may  alone  be  the  cause  of  the  disease. 

Many  acute  febrile  diseases  are  occasionally  accom- 


180  DISEASES  OF  THE  SPINAL   CORD. 

panied  by  a  myelitis;  this  will  be  referred  to  agaia 
(post-febrile  paralysis). 

Lead-poisoning  is  not  nnfrequently  the  cause  of 
symptoms  closely  resembling  those  of  myelitis ;  in- 
deed, it  is  probable  that  in  such  cases  there  is  inflam- 
mation of  the  spinal  cord,  but  generally  of  a  chronic 
form. 

Excess  in  venery,  and  syphilis,  may  give  rise  to 
myelitis  ;  so  may  injuries  to  the  back,  from  falls,  blows, 
etc. 

Severe  emotions,  as  fright  and  anger,  may  occasion- 
ally give  rise  to  inflammation  of  the  spinal  cord. 

Pathological  Anatomy. — The  spinal  cord  affected 
with  acute  myelitis  is  generally  softened,  but  occasion- 
ally its  consistency  is  increased.  The  softening  may 
be  only  slight,  or  the  cord  may  be  quite  liquid.  The 
color  is  either  reddish,  if  there  is  an  admixture  of  blood 
with  the  debris  of  the  cord,  or  yellow,  if  fatty  degen- 
eration has  occurred  to  any  extent,  or  white.  The  soft- 
ening may  occupy  a  continuous  stretch  of  the  cord, 
or  it  may  be  scattered  about  in  isolated  spots  ;  the  gray 
substance  is  rather  more  easily  affected  than  the  white. 

The  dorsal  region  is  more  frequently  the  seat  of 
softening  than  either  the  cervical  or  lumbar.  When 
the  cervical  region  is  affected,  it  is  said  that  the  dis- 
seminated variety  is  the  more  common. 

Above  the  portion  directly  affected  there  is  found 
secondary  ascending  degeneration  of  the  posterior  col- 
umns and  cerebellar  tracts  ;  below,  secondary  descend- 
ing degeneration  of  the  pyramidal  tracts.  This  second- 
ary degeneration  can  be  best  seen  from  the  change  of 
color  after  hardening  in  bichromate  of  potassa  or  chro- 
mic acid. 

With  the  microscope,  the  minute  changes  of  struct- 
ure may  be  studied  better  upon  hardened  specimens. 
Either  the  nervous  structures  are  chiefly  affected,  or  the 
interstitial  tissue  is  first  altered.  The  nerve-fibers  are 
first  swollen,  the  myeline  becomes  granular,  and  the 


ACUTE  MYELITIS.  181 

axis  cylinder  is  either  broken  up  and  disappears  or  is 
enlarged,  even  to  ten  times  its  normal  diameter ;  these 
enlarged  axis- cylinders  may  be  iilled  with  cavities — 
vacuoles  ;  the  enlargement  is  varicose  or  affects  only  a 
short  length  of  the  axis ;  it  may  be  spherical  or  fusi- 
form. These  enlarged  axes  soon  break  up  and  disap- 
pear in  the  general  debris  of  the  softened  tissue.  When 
the  cord  acquires  increased  consistency,  this  hypertro- 
phy of  the  nerve-fibers  is  either  entirely  wanting  or  is 
very  slight. 

The  nerve-cells  are  also  swollen,  acquire  a  globular 
appearance,  their  outline  may  be  less  distinct  than  nor- 
mal, and  the  nucleus  may  be  pushed  to  one  side,  even 
so  as  to  project  beyond  the  general  outline  of  the  cell ; 
they  may  be  filled  with  vacuoles,  or  they  may  have  a 
shining,  glassy  appearance — vitreous.  There  may  be  a 
large  deposit  of  pigment  in  the  cells.  They  finally 
become  granular,  break  up,  and  disappear. 

Changes  in  the  neuroglia  may  be  the  starting-point 
in  myelitis ;  then  those  in  the  nervous  structures  are 
secondary,  and  there  is  less  likely  to  be  hypertrophy 
of  the  nerve-fibers  and  cells.  The  nuclei  of  the  neurog- 
lia multiply,  the  fibers  swell  up  and  are  thicker,  and 
they  become  brittle  and  undergo  fatty  degeneration. 
Granular  corpuscles  form  at  the  expense  of  the  nuclei 
and  connective  tissue.  As  the  nutrition  of  the  nervous 
elements  is  interfered  with,  they  also  degenerate,  and 
the  cord  is  soon  reduced  to  a  soft,  semi-liquid  consist- 
ency. When  the  cord  acquires  an  increased  consist- 
ency, the  fibers  and  cells  of  the  neuroglia  are  multiplied 
somewhat  as  in  sclerosis,  though  to  a  less  degree ;  the 
nerve-fibers  in  these  cases  are  destroyed,  and  their  place 
is  filled  with  granular  debris  or  a  liquid  which  becomes 
granular  on  hardening. 

The  walls  of  the  blood-vessels  are  rarely  if  ever 
thickened  in  acute  myelitis ;  they  are  more  likely  to 
lose  consistency  and  rupture  easily,  giving  rise  to  haem- 
orrhages which  aid  in  the  process  of  disintegration. 


182  DISEASES  OF  THE  SPINAL   CORD. 

The  walls  of  tlie  vessels  are  often  covered  with,  granular 
corpuscles. 

Symptoms. — Acute  myelitis  may  begin  with  a  chill 
and  fever  before  any  distinctive  spinal  or  nervous  symp- 
toms appear.  The  temperature  only  rarely  reaches 
104°  ;  the  pulse  may  be  as  high  as  150 ;  with  the  py- 
rexia are  the  usual  constitutional  symptoms — anorexia, 
headache,  and  general  malaise. 

Very  frequently  the  commencement  of  the  disease 
is  more  gradual ;  a  sense  of  weariness,  heaviness,  with 
backache  and  undefined  sensations  in  the  limbs,  precede 
the  initial  fever. 

Soon  after  the  chill  and  fever,  sometimes  without 
any  distinct  pyrexia,  a  numbness  or  a  pricking  and 
tingling  is  noticed,  usually  in  the  toes  and  feet.  These 
abnormal  sensations  increase  in  severity  and  gradually 
extend  up  the  leg. 

With  these  symptoms,  or  soon  after  their  advent, 
rarely  as  the  initial  symptom,  the  patient  is  aware  of  a 
loss  of  strength  in  his  legs  ;  he  is  soon  wearied  in  walk- 
ing ;  in  a  very  short  time  this  increases,  so  that  he  is 
unable  to  walk,  and  must  keep  his  bed.  In  many  in- 
stances there  is  tremor  or  cramps  at  the  beginning  of 
the  attack,  but  no  marked  convulsions  nor  spasms. 

The  disturbance  of  motion  and  sensation  extends 
upward,  affecting  both  limbs  with  increasing  and  nearly 
equal  severity,  until  there  may  be  entire  paralysis  of 
motion  and  complete  loss  of  sensation  in  the  legs. 

The  different  reflexes,  cutaneous  and  deep-seated, 
are  first  diminished,  then  lost,  unless  the  myelitis  is 
limited  to  a  comparatively  short  segment  of  the  cord 
above  the  lumbar  region.  The  reflex  actions  which 
control  the  bladder  and  rectum  are  lost ;  there  is,  at 
first,  usually  retention  of  urine ;  later  the  urine  drib- 
bles away  from  over-distention  of  the  bladder  and  pa- 
ralysis of  the  sphincter.  There  is  constipation  rather 
than  involuntary  action  of  the  bowels. 

A  sense  of  constriction,  girdle  sensation,  is  noticed 


ACUTE  MYELITIS.  183 

around  the  thighs — later  around  the  waist.  This  may- 
be very  annoying  to  the  patient. 

As  the  inflammation  extends  upward  in  the  cord, 
the  trunk  is  affected,  the  costal  respiratory  muscles 
cease  to  act,  the  respiration  becomes  diaphragmatic, 
there  is  inability  to  expel  the  mucus  which  may  accu- 
mulate in  the  bronchial  tubes  ;  the  breathing  therefore 
becomes  noisy,  the  upper  extremities  are  also  affected, 
the  patient  finally  ceases  to  breathe,  and  dies  of  apnoea. 

When  the  inflammation  extends  downward  rather 
than  upward,  its  progress  can  be  recognized,  though 
less  certainly,  by  observing  the  loss  of  reflexes  in  a  de- 
scending order,  or  the  gradual  extinction  of  electrical 
reactions.  For  this,  careful  comparative  examinations 
are  necessary,  such  as  it  is  not  always  desirable  to 
make. 

Pain  is  not  a  prominent  symptom  in  acute  myelitis ; 
it  is  not  present  unless  the  membranes  are  also  impli- 
cated. The  tingling  numbness  may  be  so  severe  as  to 
give  the  patient  much  discomfort,  and  there  may  be 
aching  and  a  sense  of  unrest  in  the  limbs  ;  but  it  is  not 
rare  to  have  the  disease  run  its  course  vdthout  even  this 
amount  of  discomfort.  Backache  is  said  by  some  to  be 
one  of  the  symptoms  of  acute  myelitis ;  if  this  is  promi- 
nent, there  is  probably  an  accompanying  meningitis. 
There  is  no  tenderness  over  the  spinous  processes,  and 
spontaneous  spasms  or  evidences  of  reflex  irritability 
are  wanting.  Pain  or  tenderness  may  be  shown  by 
passing  a  sponge  wet  with  hot  water,  or  a  lump  of  ice, 
over  the  back ;  a  severe  burning  sensation  will  be  felt 
at  the  seat  of  the  lesion.  Electricity  will  sometimes  act 
in  the  same  way.  Hypersesthesia  of  the  skin  is  not 
found  in  myelitis,  excepting  occasionally  a  narrow  zone 
at  the  upper  limit  of  the  region  affected  with  anaesthe- 
sia. Symptoms  of  motor  and  sensory  irritation,  how- 
ever, are  often  seen  in  cases  of  myelitis,  because  very 
frequently  the  membranes  are  implicated. 

A  tonic  contraction  of  the  legs,  a  rigidity  in  exten- 


184  DISEASES  OF  THE  SPIFAL   COED. 

sion,  is  a  symptom  which  belongs  to  the  later  stages, 
when  the  disease  is  above  the  lumbar  enlargement; 
there  is  then  difficnlty  in  abducting  the  legs,  and  pass- 
ing a  catheter  may  become  difficult  from  the  exaggera- 
tion of  this  contraction  caused  thereby. 

The  urine  may  become  alkaline  early  in  the  disease, 
as  Erb  thinks,  not  improbably  from  direct  nervous  dis- 
turbance of  the  secretory  functions.  There  is  always 
danger,  also,  of  this  change  in  the  urine  from  retention, 
the  bladder  being  only  imperfectly  emptied.  Cystitis 
is  one  of  the  complications  to  be  watched  for.  When 
the  lumbar  enlargement  is  not  affected,  the  urine  may 
be  passed  involuntarily,  and,  if  sensation  is  much  dis- 
turbed, without  the  patient's  knowledge.  Bed-sores 
sometimes  form  with  great  rapidity,  enormous  masses 
of  tissue  sloughing  away  and  giving  rise  to  possible 
purulent  infection.  Even  if  such  acute  disturbance  of 
nutrition  does  not  occur,  it  is  very  common  to  have 
a  more  slowly  developed  bed-sore.  An  eruption  of 
herpes,  buUse,  or  pemphigus  may  appear  on  the  limbs. 

The  nerves  arising  from  the  part  of  the  cord  affected 
and  the  muscles  supplied  by  them  undergo  destructive 
degeneration,  and  there  may  be  wasting  of  the  limbs, 
appearing  more  or  less  rapidly.  The  electrical  reaction 
is  affected  under  these  circumstances,  there  being  the 
reaction  of  degeneration. 

Above  and  below  the  principal  focus  of  disease  there 
will  be  secondary  degeneration  if  the  patient  lives  long 
enough.  Then  there  may  be  found  the  exaggerated 
tendon  reflexes  and  other  symptoms  belonging  to  lesion 
of  the  lateral  pyramidal  tracts. 

This  description  has  been  rather  that  of  a  severe 
case,  which  runs  its  course  to  a  fatal  termination.  Fre- 
quently the  symptoms  are  less  grave  :  sensation  is  not 
entirely  abolished  in  the  legs  ;  the  reflexes  are  not  ab- 
solutely lost ;  perhaps  one  side  is  chiefly  affected,  the 
other  slightly  so  ;  after  a  variable  length  of  time  there 
is  a  recession  of  the  symptoms,  the  disease  has  ceased 


ACUTE  MYELITIS.  185 

to  advance,  and  tlie  patient  is  recovering.  The  recov- 
ery is  almost  never  complete.  There  generally  remains 
some  impairment  of  function. 

As  an  unusual  complication  may  be  mentioned  op- 
tic neuritis,  occurring  at  the  same  time  or  just  preced- 
ing subacute  myelitis,  as  observed  by  Erb.  He  thinks 
that  the  optic  nerves  and  the  spinal  cord  are  both  easily 
affected  by  the  same  injurious  influences,  and  so  may 
together  be  attacked  vdth  subacute  inflammation. 

Diagnosis. — It  is  necessary  to  distinguish  acute 
myelitis  from  meningitis,  haemorrhage,  and  acute  as- 
cending paralysis. 

It  is  also  desirable  to  form  an  opinion  as  to  the  part 
of  the  cord  affected. 

In  meningitis  there  is  much  more  severe  pain,  both 
in  the  limbs  and  back — such  pain  as  to  cause  the  pa- 
tient to  complain  of  it  bitterly ;  this  pain  is  increased 
upon  motion.  There  is  often  great  hypersesthesia  of  the 
limbs  ;  fever  runs  higher  in  meningitis  than  in  myelitis  ; 
reflex  actions  are  much  more  exaggerated  and  the  con- 
tractions are  more  constant,  and  the  limbs  may  be 
flexed,  or  there  may  be  opisthotonus.  Paralysis  is  a 
later  symptom  in  meningitis ;  trophic  disturbances  of 
the  skin  are  rare. 

Hsemorrhage  is  distinguished  by  the  suddenness 
with  which  the  initial  symptoms  arise,  without  fever, 
the  injury  preceding  the  disease,  or,  if  spontaneous,  the 
severe  pain  preceding  or  attending  the  commencement 
of  the  attack.  The  stationary  character  of  the  symp- 
toms after  the  first  attack,  or  their  gradual  extension 
secondarily,  also  when  the  cervical  and  lumbar  enlarge- 
ments are  the  seat  of  the  haemorrhage,  the  rapid  wast- 
ing and  loss  of  electrical  reaction,  aid  in  forming  a  diag- 
nosis. If,  however,  the  history  of  the  case  is  imperfect, 
a  diagnosis  may  be  extremely  difficult. 

Acute  ascending  paralysis  may  be  diagnosticated  by 
the  fact  that  sensation  is  little  if  at  all  affected ;  the 
bladder  and  rectum  are  not  likely  to  be  disturbed; 


186  DISEASES  OF  THE  SPINAL   GORD. 

there  is  no  bed-sore ;  the  muscles  do  not  undergo  atro- 

pty. 

The  diagnosis  of  the  seat  of  the  lesion  must  be  made 
from  a  study  of  the  symptoms,  keeping  in  mind  the 
physiology  of  the  cord.  Unilateral  acute  myelitis  is 
almost  never  seen,  excepting  as  the  result  of  injuries, 
and  need  not  be  specially  considered.  In  most  instances 
the  central  gray  substance  is  first  affected ;  the  dis- 
ease spreads  then  to  the  white  substance.  If  the  an- 
tero-lateral  columns  are  first  affected,  there  will  be 
loss  of  motor  power,  and,  if  the  disease  begins  in  the 
pyramidal  tracts,  the  symptoms  of  lesion  of  those  tracts. 
A  much  less  extent  of  disease  of  the  motor  tracts  will 
cause  paralysis  of  motion  than  is  necessary  to  give  rise 
to  loss  of  sensation ;  indeed,  if  but  a  small  portion  of 
the  gray  substance  is  left,  sensation  is  not  entirely  de- 
stroyed. 

Myelitis  is  much  more  common  in  the  dorsal  region, 
possibly  explained  by  its  vascular  supply  being  less 
sure,  as  pointed  out  by  Adamkiewicz. 

An  examination  of  the  reflexes,  as  suggested  by 
Gowers,  will  aid  in  fixing  the  upper  limit,  and  some- 
times the  lower  limit,  of  the  disease ;  so  will  a  careful 
study  of  the  muscles  paralyzed  and  of  the  region  af- 
fected with  anaesthesia,  by  which  means  we  can  recog- 
nize what  nerves  have  lost  their  function. 

Peogistosis. — When  myelitis  begins  violently  and 
the  paralysis  advances  rapidly,  the  prognosis  is  un- 
favorable; the  same  is  true  when  the  disease  has 
reached  or  has  commenced  in  the  cervical  region,  and 
especially  if  respiration  is  disturbed.  If  there  is  much 
cystitis,  or  if  bed-sores  form,  the  prognosis  is  unfavor- 
able, even  if  other  symptoms  seem  mild,  and  the  more 
so  if  the  general  health  suffers  severely  and  if  the  pa- 
tient's constitution  seems  undermined.  It  is,  however, 
of  ten  impossible  to  convince  either  the  patient  or  his 
friends  that  he  must  die,  so  little  discomfort  does  he 
experience. 


ACUTE  MYELITIS.  187 

The  more  gradual  the  advance  of  the  disease,  and 
the  more  incomplete  the  loss  of  function,  the  more 
favorable  is  the  prognosis.  A  slight  remission  of  symp- 
toms and  sustained  general  strength  are  also  favorable. 

Even  when  the  patient  has  apparently  nearly  re- 
gained his  health,  a  relapse  is  possible,  and,  after  one 
attack,  a  slight  imprudence  may  cause  another,  so  that 
the  patient  must  take  extra  care  of  himself. 

Teeatmeitt. — As  soon  as  the  disease  is  recognized, 
the  patient  should  be  put  to  bed  and  kept  there.  As 
perfect  rest  of  mind  and  body  as  possible  is  absolutely 
necessary,  even  against  the  protest  of  the  patient,  who 
may  be  conscious  of  only  slight  numbness  or  weakness. 

Ice-bags  to  the  spine,  applied  continuously,  are  of 
benefit  in  meningitis,  and  may  be  used  in  myelitis, 
though  their  value  is  less  certain.  A  mild  form  of 
counter-irritation,  dry-cupping,  is  of  value,  and  should 
be  employed ;  two  to  six  or  eight  cups  can  be  applied 
daily ;  usually  two  are  sufficient,  changing  their  place 
each  time.  The  cups  should  remain  on  about  half  an 
hour,  and  should  leave  the  skin  much  congested  when 
removed.  If  the  attack  is  very  severe,  the  danger  of 
bed-sores  may  contra-indicate  cupping. 

Ergot,  drachm  doses  of  fluid  extract,  or  six  or  eight 
grains  of  ergotin,  should  be  given  three  times  a  day. 
This  may  be  combined  with  one  of  the  preparations  of 
belladonna. 

Iodide  of  potassium  may  be  used  even  in  the  earlier 
stages  with  advantage,  and  later  even  more  efficacious- 
ly, especially  where  syphilis  is  suspected,  and  in  those 
cases  mercury  may  be  combined  with  it. 

The  greatest  care  should  be  taken  to  sustain  the  pa- 
tient's nutrition,  to  relieve  the  bowels,  to  prevent  cysti- 
tis and  bed-sores. 

When  the  patient  is  recovering,  electricity  can  be 
used  to  maintain  the  nutrition  of  the  muscles ;  this 
may  be  combined  with  massage,  or  the  latter  can  be 
used  alone. 


188  DISEASES  OF  THE  SPINAL   COED. 

Counter-irritation  to  tlie  back,  actual  cautery,  and 
dry-cupping  may  be  employed  during  recovery,  but 
are  of  doubtful  efficacy  then. 

CHRONIC   MYELITIS. 

Chronic  myelitis  sometimes  succeeds  acute  myelitis, 
or  may  result  from  injuries.  It  may  also  follow  expos- 
ure to  cold,  fatigue,  and  long-continued  emotional  dis- 
turbances ;  tlie  eruptive  fevers  and  other  acute  diseases 
may  be  complicated  with  chronic  changes  in  the  spinal 
cord ;  syphilis  is  a  very  common  cause.  In  many  cases 
it  will  be  found  that  lead  has  been  received  into  the  sys- 
tem. So  frequently  is  lead  one  element  in  the  aetiology, 
that  it  should  be  sought  for  in  every  case.  Arsenic  may 
give  rise  to  the  same  symptoms. 

Pathological  Anatomy. — After  death  the  spinal 
cord  is  sometimes  found  softened;  more  frequently, 
however,  it  is  found  firmer  in  consistency  than  normal. 
The  seat  of  the  inflammatory  changes  may  vary  in  dif- 
ferent cases ;  sometimes  the  gray  substance  is  chiefly 
affected,  sometimes  the  white  substance,  and  more  fre- 
quently both  gray  and  white  are  affected ;  sometimes 
the  disease  extends  through  the  whole  thickness  of  the 
cord,  and  sometimes  only  one  half  is  affected ;  again, 
only  the  periiDhery  of  the  cord  is  diseased — chronic  cor- 
tical myelitis,  as  it  has  been  caUed. 

The  microscopic  changes  vary  according  as  the  con- 
nective tissue  (neuroglia)  or  the  nerve-fibers  and  cells 
are  chiefly  affected.  If  the  neuroglia  is  primarily  dis- 
eased, we  have  thickening  of  the  connective  tissue  with 
increase  of  its  elements ;  secondary  to  these  changes 
the  nervous  elements  gradually  disappear. 

When  the  latter  are  chiefly  affected,  they  pass 
through  changes  similar  to  those  found  in  acute  mye- 
litis ;  the  neuroglia  may  be  somewhat  thickened,  or  it 
may  apparently  suffer  no  change. 

The  walls  of  the  blood-vessels  are  usually  somewhat 
thickened.     The  tissue  around  the  vessels  may  undergo 


CHRONIG  MYELITIS.  189 

granular  degeneration,  and  thus  spots  of  softening  may 
form. 

Symptoms. — The  symptoms  of  chronic  myelitis  will 
vary  somewhat  according  to  the  seat  of  the  lesion. 
The  first  symptoms  may  appear  either  in  the  sensory  or 
motor  function ;  the  motor  phenomena  consist  in  a 
gradually  increasing  weakness,  affecting  one  or  more 
limbs,  the  first  sign  of  failure  being  a  sense  of  heavi- 
ness in  the  legs  or  arms,  and  an  unusual  liability  to 
become  fatigued.  These  symptoms  slowly  increase  in 
severity,  the  weakness  becomes  more  marked,  and  the 
patient  may  be  confined  to  his  bed  many  months  be- 
fore there  is  entire  paralysis.  There  are.  rarely  spasms  ; 
but  chronic  contractures  are  not  so  infrequent,  the  legs 
being  held  in  extension  and  adducted,  rarely  flexed. 
Reflex  actions  are  sometimes  moderately  exaggerated ; 
this  is  often  shown  simply  by  an  increase  of  the  pre- 
existing contraction :  thus,  if  it  is  desired  to  draw  off 
the  water,  the  introduction  of  a  catheter  may  increase 
the  adduction  of  the  thighs  so  as  to  render  the  opera- 
tion very  difficult,  especially  in  a  female.  The  tendon 
reflexes  are  sometimes  exaggerated  and  sometimes  di- 
minished, according  to  the  location  of  the  disease. 
When  the  anterior  gray  substance  is  affected,  there  is, 
of  course,  wasting  of  the  muscles,  in  which  case  the 
electrical  phenomena  undergo  the  usual  changes ;  other- 
wise the  electrical  reactions  may  even  be  exaggerated. 

Disturbances  of  sensation  appear  very  early,  and  are 
often  the  first  symptom  to  attract  the  patient's  atten- 
tion. These  disturbances  are  often  simply  a  sense  of 
numbness  and  tingling,  as  if  the  limbs  had  been  asleep, 
without  any  disturbance  of  tactile  sensibility ;  but 
sometimes  the  sense  of  touch  is  affected,  and  there  is 
more  or  less  marked  anaesthesia.  Pain  is  not  very 
common,  but  is  occasionally  very  severe.  In  some  cases 
there  is  hypergesthesia  to  touch,  or  the  sense  of  touch 
is  perverted  so  as  to  give  rise  to  a  peculiar  vibrating 
pain.     This  sensory  disturbance  may  remain  limited  to 


190  DISEASES  OF  THE  SPINAL   COED. 

one  limb,  to  a  toe  or  finger,  during  several  weeks  be- 
fore extending,  or  before  other  symptoms  appear. 

The  condition  of  the  bladder  and  rectum  varies  ac- 
cording to  the  seat  of  the  lesion.  There  is  danger  of 
cystitis  when  urine  is  retained,  as  in  the  acute  form. 
The  sexual  function  is  gradually  abolished,  though 
occasionally  the  sexual  appetite  may  be  increased. 
After  the  patient  is  confined  to  bed,  bed-sores  are  liable 
to  form,  especially  if  cleanliness  is  neglected. 

The  disease  is  slowly  progressive  toward  a  fatal  ter- 
mination, but  there  are  occasionally  periods  of  remis- 
sion and  improvement  which  may  be  so  great  as  to 
encourage  the  hope  of  final  recovery  ;  but  some  impru- 
dence or  exposure  starts  up  the  inflammation  again, 
and  causes  an  aggravation  of  the  symptoms.  Death 
may  not  occur  for  several  years  after  the  commence- 
ment of  the  disease. 

Diagnosis. — In  well-marked  cases  this  form  of 
myelitis  is  not  likely  to  be  mistaken  for  other  diseases 
of  the  spinal  cord ;  but  in  some  instances  it  may  be 
doubtful  whether  there  is  locomotor  ataxia,  multiple 
sclerosis,  lateral  sclerosis,  or  disease  of  the  anterior 
cornua.  When  multiple  sclerosis  affects  chiefly  the 
spinal  cord,  it  may  be  impossible  to  make  a  correct 
diagnosis. 

Yulpian  says:  "Every  time  there  is  found  in  a 
chronic  affection  of  the  cord  an  irregular  course  of  the 
disease — causing  weakness  and  paralyses  of  different 
parts  of  the  body,  giving  rise  to  combinations  of  symp- 
toms belonging  some  to  one  systematic  lesion,  some  to 
another,  and  presenting,  as  a  whole,  symptoms  which, 
except  for  the  rapidity  of  their  appearance  and  their 
succession,  would  be  more  or  less  similar  to  those  no- 
ticed in  acute  diffuse  myelitis — it  may  be  asserted  that 
it  is  a  case  of  chronic  diffuse  myelitis. 

"Whenever,  in  any  chronic  affection  of  the  cord, 
the  assemblage  of  symptoms  allows  the  elimination  of 
systematic  lesions,  of  sclerosis  in  patches,  of  chronic. 


CHRONIG  MYELITIS.  191 

myelitis  of  the  anterior  cornua,  tlie  case  is  one  of 
chronic  diffuse  myelitis." 

Progn^osis. — The  disease  is  one  of  long  duration 
and,  as  has  been  said,  with  periods  of  remission  and 
improvement.  Complete  recovery  is  extremely  rare, 
except  in  cases  caused  by  lead  or  those  occurring  after 
fevers ;  it  probably  never  occurs,  there  always  being 
some  impaired  function  remaining  to  show  that  mis- 
chief has  been  done  to  the  cord. 

In  judging  whether  there  is  immediate  danger  to 
life,  the  circumstances  of  each  case  must  be  taken  into 
account,  and  no  general  directions  can  be  given. 

Treatment.  — Active  measures,  such  as  are  used  in 
acute  myelitis,  would  be  entirely  out  of  place  in  chronic 
myelitis. 

Dry-cupping,  the  actual  cautery,  the  iron  being 
heated  to  a  white  heat  and  drawn  rapidly  and  lightly 
over  the  back,  so  as  to  simply  char  the  cuticle  without 
producing  suppuration,  small  blisters  applied  in  suc- 
cession along  the  spine,  and  iodine,  may  be  employed 
as  counter-irritants  ;  of  these,  the  best  are  dry- cupping 
and  the  actual  cautery.  Brown- Sequard  recommends 
a  douche  of  hot  water  to  the  back,  the  application  be- 
ing made  for  two  or  three  minutes  every  day. 

The  galvanic  current  may  be  used,  one  pole  being 
placed  above,  the  other  below  the  probable  seat  of  the 
disease  ;  the  direction  of  the  current  may  be  varied  at 
different  sittings,  both  electrodes  being  held  stationary, 
or  one  moved  slowly  up  and  down  the  back  ;  rather  a 
weak  current  should  be  used,  only  for  a  few  minutes  at 
a  time,  the  application  being  made  daily,  and  the  treat- 
ment persevered  in  for  months.  Sometimes  this  treat- 
ment will  give  rise  to  unpleasant  symptoms  ;  it  should 
then  be  discontinued.  Erb  says  that  he  has  obtained 
benefit  in  fifty-two  out  of  one  hundred  cases  treated  by 
galvanism. 

Erb  says  :  "The  water-cure  is,  all  things  considered, 
one  of  the  most  important  and  most  promising  means 


192  DISEASES  OF  THE  SPINAL    CORD. 

of  treating  chronic  myelitis.  The  mistrust  with  which 
it  is  regarded  by  some  authors  is,  as  far  as  my  own  ex- 
perience goes,  entirely  unjustifiable.  It  is  suitable  for 
most  all  cases,  though,  of  course,  the  method  of  appli- 
cation must  vary  according  to  the  peculiarities  of  the 
individual  cases. 

"  Simple  rubbing  with  wet  cloths,  foot-baths,  spong- 
ing the  back,  hip-baths,  half -baths,  with  affusions  to 
the  back,  local  compresses  to  the  back,  left  on  till  they 
become  warm,  etc.,  seem  to  be  the  measures  which  are 
chiefly  applicable.  The  treatment  should  always  be 
begun  with  moderate  temperatures  (20°  to  25°  C,  or 
68°  to  77°  F.),  and  we  should  never  go  below  16°  to  12° 
C.  (60|-°  to  53f°  F.).  I  believe,  also,  that  excessive  pro- 
longation of  the  treatment  is  injurious." 

Of  internal  remedies,  nitrate  of  silver,  a  quarter  to 
half  a  grain  three  times  a  day  for  four  or  five  weeks, 
then  omitted  for  a  short  time  ;  ergot,  half  a  drachm  to 
a  drachm  of  the  fluid  extract  three  times  a  day  ;  double 
chloride  of  gold  and  sodium,  gr.  -^  three  times  a  day  ; 
ext.  of  belladonna,  gr.  ^  to  -I-  twice  or  three  times  a 
day  ;  iodide  of  potassium  should  be  used  if  there  is 
lead,  and  anti-syphilitic  treatment  when  it  is  indicated. 

In  chronic  myelitis  there  is  less  reason  to  keep  the 
patient  quiet  and  at  rest  than  in  acute  myelitis ;  yet 
over-exertion  should  be  carefully  avoided.  It  is  much 
more  prudent  to  restrain  the  patient's  activity  more 
than  is  necessary  than  to  allow  even  a  slight  over-ex- 
ertion. The  same  may  be  said  of  all  imprudent  expo- 
sures to  influences  which  are  likely  to  cause  the  disease. 

ACUTE  ASCENDING  PARALYSIS. 

This  is  sometimes  called  Landry's  paralysis,  because 
Landry  first  described  the  combination  of  symptoms. 

It  is  defined  by  Erb  as  "a  motor  paralysis  which 
generally  begins  in  the  lower  extremities,  spreads  pretty 
rapidly  over  the  trunk  to  the  upper  extremities,  and 
usually  also  involves  the  medulla  oblongata,  which 


ACUTE  ASCENDING  PARALYSIS.  193 

sometimes  runs  its  course  without  fever,  sometimes 
with  more  or  less  active  fever,  which  but  slightly  in- 
volves the  general  sensibility  and  the  functions  of  the 
bladder  and  rectum,  and  which  runs  its  course  without 
notable  atrophy  of  the  muscles,  and  without  any  dimi- 
nution or  change  in  their  electrical  excitability," 

This  definition  gives  nearly  the  whole  symptoma- 
tology of  the  disease.  It  is  only  necessary  to  add  that 
prodroma,  disturbed  sensations,  numbness,  and  aching 
in  back  and  limbs,  may  precede  the  motor  paralysis ; 
that  the  disease  may  commence  in  the  upper  extremity ; 
that  reflex  actions  may  be  much  diminished  or  entirely 
lost ;  the  tendon  reflex  has  not  been  carefully  studied  ; 
and  the  functions  of  the  brain  do  not  seem  disturbed 
until  just  before  death. 

The  disease  usually  ends  fatally  when  the  nerves 
arising  from  the  medulla  are  affected.  The  symptoms 
may  cease  to  advance  at  almost  any  stage,  may  recede, 
and  the  patient  may  recover. 

The  symptoms  recall  those  which  are  found  in 
acute  or  subacute  anterior  poliomyelitis ;  the  reten- 
tion of  electrical  reaction  in  the  muscles  is  the  chief 
difference. 

Many  cases  have  been  examined  after  death,  and  no 
lesions  discovered  in  the  cord. 

"^Yhen  Landry  described  this  form  of  paralysis  in 
1859,  the  electrical  reaction  of  muscles  was  not  taken 
into  account  in  forming  a  cfiagnosis,  and  there  seems  no 
special  reason  why  that  should  be  added  in  order  to 
form  a  distinct  disease.  Several  autopsies  (Eisenlohr, 
Fox,  V.  d.  Yelden,  Peabody)  have  lately  shown  that 
there  are  changes  in  the  cord ;  though  these  changes 
have  seemed  to  be  very  slight,  yet  they  have  been  quite 
diffused,  and  are  such  as  may  indicate  an  early  stage 
of  myelitis,  sometimes  affecting  the  white  substance, 
sometimes  the  gray ;  sometimes  attended  with  no 
change  in  electrical  reaction,  sometimes  accompanied 
with  such  change.    IvTo  case  has  yet  been  reported  in 

13 


X94  DISEASES  OF  THE  SPINAL   GOBD. 

which  a  proper  examination  of  the  peripheral  nerves 
has  been  made. 

The  causes  of  this  form  of  paralysis  are  said  to  be 
the  same  as  those  of  myelitis  ;  the  treatment  should  be 
the  same  as  in  acute  myelitis. 

It  is  not  my  purpose  to  enter  upon  a  long  discussion 
of  any  doubtful  points.  In  view  of  the  cases  which 
have  been  published,  I  can  see  no  satisfactory  reason 
for  retaining  acute  ascending  paralysis  as  the  name  of 
a  distinct  disease ;  the  cases  coming  under  that  desig- 
nation can  be  included  under  one  of  the  forms  of  acute 
or  subacute  myelitis. 


CHAPTER  XYI. 

POLIOMYELITIS. — MYELITIS   OF  ANTEEIOE  COENUA. 

Petitfils,  a.  ,  Considerations  sur  1'atroph.ie  aigue  des  cellules 
matrices.  Paris,  1873. — Gombault,  Note  sur  un  cas  de  paralysie 
spinale  de  I'adulte,  suivi  d'autopsie.  Arch,  de  physiol.,  1873. — 
Bernhardt,  Ueber  eine  der  spinale  Kinderlahmung  ahnliche  Af- 
fection Erwachsener.  Arch.  f.  Psych,  u.  Nervenkr. ,  1874,  p.  370. 
— Bennett,  A.  H.,  On  Chronic  Atrophic  Spinal  Paralysis  in  Chil- 
dren. Brain,  Oct.,  1883,  p.  289.— Seguin,  E.  C,  Myelitis  of  the 
Anterior  Horns.  New  York,  1877.— Proust,  A.,  and  Ballet,  G., 
Contribution  a  I'anatomie  pathologique  de  la  paralysie  generale 
spinale  diffuse  subaigue  de  Duchenne.  Arch,  de  physiol.,  Oct., 
1883,  p.  330. 

ACUTE  ANTERIOK  POLIOMYELITIS. 

This  is  tlie  name  that  has  lately  been  given  to  a  class 
of  diseases  characterized  by  changes  in  the  anterior  cor- 
nna.  These  changes  are  generally  considered  to  be  of 
an  inflammatory  nature. 

The  so-called  infantile  paralysis  was  for  a  long  time 
the  only  recognized  manifestation  of  this  disease,  but 
during  the  last  ten  years  or  so  cases  have  been  reported 
as  occurring  among  adults  having  very  nearly  the  same 
symptoms,  and  after  death  presenting  similar  lesions  of 
the  anterior  cornua. 

It  ought  to  be  mentioned  that  some  authors  consider 
this  affection  primarily  a  disease  of  the  muscles.  This 
view  is  not  generally  accepted.  Leyden  refers  the 
symptoms  in  some  cases  to  a  diffused  or  general  neuri- 
tis. 

Etiology. — By  far  the  larger  number  of  patients 


196  DISEASES  OF  THE  SPIRAL   CORD. 

are  infants  from  one  to  three  years  of  age ;  among 
adults,  tlie  larger  number  are  attacked  between  the 
years  of  twenty  and  forty ;  between  the  years  from 
four  to  fourteen  there  seems  to  be  comparative  exemp- 
tion from  this  form  of  myelitis.  During  infancy  both 
sexes  are  about  equally  liable  to  the  disease ;  among 
adults,  males  are  rather  more  frequently  attacked  than 
females. 

During  dentition  the  nervous  system  of  a  child  is  in 
a  more  irritable  state,  and  perhaps  more  likely  to  suf- 
fer from  injurious  influences  ;  this  may  explain  the  fre- 
quency with  which  infantile  paralysis  occurs  during  the 
first  and  second  years. 

Cold  acting  upon  the  surface  of  the  body  may  be  a 
cause  of  this  form  of  myelitis  as  of  other  forms.  In  a 
very  few  cases  I  have  been  able  to  learn  that  during  the 
night  preceding  the  occurrence  of  the  paralysis  the  child 
has  been  found  to  have  kicked  off  the  clothing,  and 
thus  become  chilled. 

Falls  and  other  injuries  have  sometimes  seemed  to 
be  a  cause.     In  adults,  excessive  exertion. 

The  summer  months  show  a  larger  proportion  of 
attacks  than  the  other  seasons. 

Pathological  Anatomy. — There  are  reasonable 
grounds  for  the  opinion  that  the  first  change  is  a  con- 
gestion of  the  anterior  cornua,  and  perhaps  of  other 
parts  of  the  cord  also.  In  the  foetus  and  in  early  in- 
fantile life  the  capillaries  more  closely  surround  the 
nerve-cells,  each  cell  being  inclosed  in  a  net-work  of 
small  vessels.  Adamkiewicz  has  shown  that  in  the 
adult  a  system  of  canals,  smaller  than  the  capillaries, 
can  be  injected  from  the  vessels  so  as  to  form  a  net- 
work, by  which  each  nerve-cell  is  surroimded.  After 
the  first  shock  of  the  disturbed  circulation,  which 
causes  the  paralysis,  the  congestion  diminishes,  and 
with  this  the  paralysis  disappears,  except  where  the  in- 
jury to  the  nutrition  of  the  cells  has  been  suflB.cient  to 
destroy  or  seriously  impair  their  vitality. 


ACUTE  ANTERIOR  POLIOMYELITIS..  197 

The  essential  chaiige  seems  to  be  destruction  of  tlie 
nerve-cells  ;  other  changes  are  either  accidental  compli- 
cations or  secondary.  When  the  patient  has  survived 
many  years,  the  affected  cornua  are  found  deformed 
and  diminished  in  size  ;  the  neighboring  white  columns 
may  also  be  misshapen. 

The  anterior  nerve-roots  arising  from  the  affected 
tract  are  atrophied  and  contain  degenerated  nerve- 
fibers,  or  the  libers  may  have  so  entirely  disappeared 
that  simply  connective  tissue  remains. 

The  muscles  undergo  change  at  a  comparatively 
early  period.  The  muscular  fibers  lose  their  transverse 
striation,  are  broken  up  into  granular  and  fatty  debris  ^ 
sometimes  the  muscular  nuclei  are  increased  in  num- 
ber ;  the  granular  and  fatty  materials  are  absorbed,  and 
there  remains  only  the  sarcolemma  with  a  larger  or 
smaller  number  of  muscular  nuclei.  Sometimes,  instead 
of  undergoing  atrophy,  the  muscles  suffer  from  a  waxy 
or  colloid  change,  in  which  the  fibers  may  be  greatly 
enlarged.  The  interstitial  tissue  is  usually  increased 
in  amount,  and  often  fat  is  deposited  between  the  mus- 
cular fibers. 

The  bones  of  the  affected  limbs  grow  less  rapidly 
than  the  corresponding  healthy  limbs,  when  the  patient 
is  a  child.  In  adults  there  is  no  atrophy  of  the  bones. 
Observations  are  not  yet  sufficiently  numerous  to  deter- 
mine whether  the  bones  become  brittle. 

Symptoms. — In  children  the  disease  begins  sudden- 
ly, sometimes,  though  rarely,  with  convulsions.  Most 
frequently  the  child,  having  been  put  to  bed  apparently 
in  good  health,  is  somewhat  restless  during  the  night, 
perhaps  awakes  and  cries,  then  sleeps  quietly  until 
morning ;  in  the  morning  it  is  discovered  that  one  or 
more  limbs  are  paralyzed ;  generally  one  or  both  legs 
are  affected ;  sometimes  the  paralysis  is  confined  to  one 
or  both  arms,  or  an  arm  and  a  leg  ;  very  rarely  are  the 
four  limbs  affected.  The  loss  of  power  may  not  be 
complete  at  first,  but  it  reaches  its  height  in  a  very  few 


198  DISEASES  OF  THE  SPIRAL   CORD. 

hours.  The  right  leg  is  said  to  be  the  most  frequently- 
affected.  Sensation  does  not  appear  to  be  much  dis- 
turbed ;  except  at  the  very  beginning,  there  seems  to 
be  no  pain,  and  it  is  doubtful  if  there  is  pain  even  at 
the  beginning.  Occasionally  a  slight  febrile  attack  pre- 
cedes the  development  of  paralysis ;  but  often  this  is  so 
slight,  especially  in  very  young  children,  and  of  such 
short  duration,  as  to  attract  little  or  no  attention,  and 
the  severity  of  the  succeeding  paralysis  is  not  propor- 
tionate to  the  amount  of  fever. 

When  convulsions  usher  in  the  attack,  they  are 
usually  of  short  duration  and  differ  materially  from  the 
severe  convulsions  of  cerebral  origin  preceding  many 
cases  of  hemiplegia  in  infants. 

Within  a  few  days,  from  two  or  three  days  to  one 
or  two  weeks,  an  improvement  in  the  paralysis  is  no- 
ticed, which  may,  in  light  cases,  advance  to  complete 
recovery,  though  more  frequently  the  improvement 
ceases  after  a  few  weeks,  leaving  some  muscles  still 
paralyzed.  Where  more  than  one  limb  is  affected,  the 
muscles  of  one  limb  may  entirely  recover,  while  those 
of  the  other  limb  or  limbs  only  partially  recover. 

Within  a  short  time  after  the  paralysis  appears,  the 
muscles  begin  to  undergo  the  atrophic  changes  already 
mentioned,  and  after  a  few  weeks  the  affected  limb 
shows  decided  evidence  of  wasting.  Its  growth  is  also 
retarded,  and  after  some  years  there  may  be  a  differ- 
ence of  from  one  to  six  or  seven  inches  in  the  length  of 
the  legs.  Erb  says  that,  while  the  atrophy  is  progress- 
ing, the  muscles  are  quite  sensitive  on  pressure. 

The  affected  muscles  show  a  change  of  electrical 
action — reaction  of  degeneration — within  a  few  days 
(four  or  five)  after  the  attack. 

The  skin  may  be  dry  and  scaly,  and  the  circulation 
sluggish,  on  account  of  which  the  limb  is  cold  and  more 
or  less  cyanotic.  Bed-sores  do  not  form,  nor  is  it  likely 
that  herpetic  and  allied  forms  of  skin  eruption  are 
caused  by  this  disease. 


ACUTE  ANTERIOR  POLIOMYELITIS.  199 

The  reflexes,  cutaneous  and  tendinous,  are  more  or 
less  disturbed  according  to  the  amount  of  muscular 
paralysis. 

After  months  or  years,  sooner  or  later,  according  to 
the  amount  of  wasting,  deformities  result.  Where  there 
is  inequality  of  the  limbs,  the  bones  of  the  pelvis  are 
tilted  and  the  spine  is  curved.  The  affected  limb  suf- 
fers also  from  contracture  ;  club-foot  and  deformity  of 
the  knee  and  hip  joint  are  seen.  The  upper  limbs  are 
much  less  frequently  subject  to  contracture  and  de- 
formity than  the  lower  limbs.  Erb  divides  the  causes 
for  these  contractures  into  three  classes  :  1.  "The  most 
frequent  cause  is  the  continued  approximation  of  the 
points  of  attachment  of  the  muscles,  induced  partly  by 
the  weight  of  the  parts,  partly  by  external  pressure  in 
walking,  standing,  etc."  2.  "The  antagonists  of  the 
paralyzed  muscles  remain  effective."  3.  "The  prolif- 
eration of  interstitial  connective  tissue  and  its  subse- 
quent retraction,  which  takes  place  with  the  degenera- 
tive atrophy  of  the  muscles." 

After  the  first  febrile  attack,  the  bladder  and  the 
rectum  are  not  affected,  and  all  the  functions  of  the 
body,  except  those  of  the  paralyzed  limbs,  are  normally 
performed.  Life  is  not  shortened  by  this  disease,  and 
the  mental  powers  of  the  child  are,  as  a  rule,  not  af- 
fected. 

In  adults  the  course  of  the  disease  is  somewhat  dif- 
ferent from  that  noticed  in  children ;  as  with  other 
febrile  affections,  convulsions  are  absent ;  pain  is  a 
rather  more  prominent  feature ;  febrile  reaction  is 
rather  more  marked,  though  it  may  be  absent ;  the  pa- 
ralysis is  developed  rather  more  slowly ;  sensibility  is 
more  frequently  disturbed  at  the  beginning,  though 
this  usually  soon  disappears ;  occasionally  vomiting 
and  gastric  disturbances  are  noticed.  After  some  days 
or  weeks,  longer  than  with  children,  the  paralysis 
amends,  and,  as  in  children,  there  may  be  complete 
recovery,  though  partial  recovery  and  wasting  are  the 


200  DISEASES  OF  THE  SPINAL   COBB. 

more  frequent  result.  Of  course,  there  is  in  adults  no 
retarded  development,  and  subsequent  deformity  is 
much  less  than  in  children.  The  electrical  reaction 
and  other  symptoms  are  almost  identical. 

Diagnosis. — The  disease  which  has  been  most  fre- 
quently confounded  with  acute  anterior  poliomyelitis 
in  children  is  hemiplegia  from  cerebral  cause.  In  this, 
convulsions  are  much  more  frequent  and  severe,  the 
paralysis  is  hemiplegic  rather  than  paraplegic,  the  elec- 
trical reactions  remain  unchanged,  contractions  resem- 
ble the  hemiplegic  contractions  found  in  adults,  and 
there  may  be  post-hemiplegic  chorea;  the  growth  of 
the  paralyzed  limbs  is  much  more  retarded. 

Haemorrhage  into  the  spinal  cord,  though  occurring 
suddenly  without  febrile  reaction  and  followed  by 
change  in  the  electrical  phenomena,  may  be  recognized 
by  the  initial  pain  which  usually  attends  it,  by  the  dis- 
turbance of  sensation,  and  the  subsequent  progress  of 
the  case,  even  partial  recovery  being  much  slower  and 
more  tedious.  The  history  of  the  case  ought  to  lead  to 
a  correct  diagnosis  from  other  diseases. 

Peogistosis. — The  prognosis,  so  far  as  life  is  con- 
cerned, is  favorable.  Complete  recovery  of  motion  in 
the  paralyzed  limbs  can  be  expected  only  in  very  mild 
cases,  and  even  in  such,  more  frequently  than  not, 
when  the  child  is  tired  there  will  be  a  slight  awkward- 
ness in  using  the  affected  limb.  Generally  the  recov- 
ery is  imperfect.  After  five  or  six  months  all  is  gained 
that  can  be  expected.  If  proper  treatment  is  pursued, 
a  much  larger  amount  of  motion  can  be  recovered  than 
when  the  child  is  left  without  treatment. 

Nothing  can  be  done  to  prevent  retardation  of 
growth,  but  deformities  resulting  therefrom  may  be  at 
least  partially  prevented  by  mechanical  appliances. 

Teeatment. — In  the  first  stage  the  fever  may  be 
combated  with  the  ordinary  measures,  and,  if  a  diagno- 
sis can  be  made  out  early,  ergot,  belladonna,  and  iodide 
of  potassium  may  be  given  in  rather  large  doses  ;  coun- 


ACUTE  ANTERIOR  POLIOMYELITIS.  201 

ter-irritation  is  also  indicated,  dry  cups  and  the  actual 
cautery  being  the  most  desirable  forms  ;  as  Seguin  sug- 
gests, tincture  of  iodine  and  blisters  cause  too  much 
pain  and  make  the  skin  sore. 

After  the  fever  has  ceased,  and  in  cases  where  there 
is  no  fever,  when  time  enough  has  elapsed  to  guard 
against  unfavorable  reaction,  electricity  should  be  used. 
The  galvanic  current  should  be  used  from  the  begin- 
ning, even  if  the  muscles  respond  to  the  faradic  cur- 
rent ;  the  positive  pole  or  anode  should  be  placed  on 
the  spine  near  the  origin  of  the  nerves  leading  to  the 
affected  muscles ;  the  negative  pole,  cathode,  should  be 
passed  slowly  over  the  muscles,  or,  the  motor  point  for 
each  muscle  having  been  found,  the  cathode  may  be 
placed  there,  and  the  current  may  be  slowly  interrupt- 
ed. Only  such  strength  of  current  need  be  used  as  wiU 
cause  perceptible  contraction  in  the  muscles.  The  ap- 
plication should  be  made  every  day  or  every  other  day 
for  about  one  minute  to  each  muscle.  The  reaction  of 
degeneration  may  appear  while  the  electricity  is  being 
used,  if  its  use  is  commenced  early. 

In  order  to  obtain  benefit  from  the  use  of  electricity, 
it  must  be  continued  for  months  ;  a  short  treatment  of 
a  few  weeks,  except  in  very  mild  cases,  would  proba- 
bly be  of  little  value.  To  obtain  the  best  results,  it 
should  be  used  as  soon  as  possible  after  all  symptoms 
of  irritation  have  ceased. 

With  children,  a  little  caution  may  be  necessary  in 
order  not  to  frighten  them  at  the  beginning  by  the  nov- 
elty of  the  application  ;  also  a  very  mild  current  should 
be  used  until  they  are  accustomed  to  the  peculiar  sen- 
sations. 

Bathing  the  affected  limbs  in  hot  water  is  of  advan- 
tage, allowing  them  to  remain  immersed  for  several 
minutes  ;  then  the  limbs  should  be  rubbed  and  knead- 
ed for  several  minutes.  The  warmth  of  the  limbs  must 
be  maintained  by  proper  clothing  or  other  means. 
Over-exercising  of  the  limbs  should  be  avoided  ;  bath- 


202  DISEASES  OF  THE  SPINAL   CORD. 

ing  and  rubbing  should  not  follow  too  closely  after  the 
use  of  electricity. 

After  all  hopes  of  further  improvement  have  to  be 
laid  aside,  much  assistance  can  sometimes  be  given  by 
orthopaedic  surgery  and  mechanical  appliances. 

Except  in  the  first  stage,  no  advantage  can  be  gained 
from  the  use  of  medicines  internally.  Hypodermic  in- 
jections of  strychnia  into  the  affected  muscles  have  been 
recommended;  but  it  is  very  doubtful  whether  more 
can  be  gained  in  this  way  than  by  the  persevering  use 
of  electricity. 

CHRONIC  ANTERIOR  POLIOMYELITIS. 

Attention  has  been  called  within  only  a  few  years 
to  a  form  of  atrophic  paralysis  which  closely  resembles 
acute  poliomyelitis,  yet  is,  in  some  respects,  different, 
the  attack  being  less  abrupt,  the  symptoms  not  exactly 
the  same.  Duchenne,  in  1872,  and  Erb,  in  his  volume 
on  the  spinal  cord,  in  Ziemssen's  "Cyclopaedia,"  in 
1877,  gave  detailed  descriptions  of  the  disease,  under 
the  name  of  poliomyelitis  anterior  suhacuta  or  chron- 
ica. Since  then  many  cases  have  been  reported,  some 
authors  preferring  to  call  it  subacuta  rather  than  cTiron- 
ica.  As  in  regard  to  several  other  forms  of  nervous 
diseases,  it  seems  that  it  was  only  necessary  to  have  at- 
tention called  to  its  peculiar  symptoms  in  order  that 
many  cases  might  be  recognized. 

E.  C.  Seguin  has  given  a  very  careful  study  to  both 
the  acute  and  subacute  or  chronic  form  of  lesion  of  the 
anterior  comua. 

When  the  cases  included  by  different  authors  are 
compared,  it  will  be  seen  that  they  are  simply  cases  of 
chronic  myelitis  in  which  the  anterior  cornua,  especial- 
ly its  nerve-cells,  are  affected  early  in  the  course  of  the 
disease  so  as  to  give  a  special  physiognomy  to  the 
symptoms.  Except  for  some  peculiarities  in  the  course 
of  the  symptoms,  it  would  not  be  desirable  to  give 
these  cases  a  separate  designation. 


CHRONIC  ANTERIOR  POLIOMYELITIS.  203 

Etiology. — ^We  must  confess  our  ignorance  of  the 
cause  of  tlie  disease  in  many  cases  ;  in  other  instances 
chronic  lead-poisoning  seems  to  be  the  chief  if  not  only 
cause  ;  certainly  in  several  patients  whom  I  have  seen 
with  this  assemblage  of  symptoms  there  was  lead  in 
the  system.  Injuries  and  chills  may  be  the  starting- 
point  in  this  as  in  other  forms  of  myelitis.  Most  of  the 
patients  are  adults.  I  have,  however,  seen  one  child 
twelve  years  old  with  the  disease,  and  an  infant  seemed 
to  have  at  first  acute  poliomyelitis,  but  later  the  disease 
followed  a  chronic  course.  It  may  occur  in  aged  per- 
sons also,  though  rarely. 

Pathological  Anatomy.  —  Very  few  autopsies 
have  been  made — only  five  or  six.  In  nearly  all  of 
these,  other  parts  of  the  cord  than  the  gray  anterior 
cornua  were  diseased.  In  a  case  reported  by  Baumler, 
the  only  change  found  was  in  the  gray  substance. 
There  is  atrophy  and  destruction  of  the  cells  of  the 
anterior  cornua ;  the  nerves  and  muscles  undergo  cor- 
responding degeneration.  Other  portions  of  the  cord 
than  the  cornua  may  also  be  affected,  and  thus  would 
be  explained  variations  in  symptoms,  the  chief  lesion, 
and  that  which  gives  its  name  to  the  disease,  being, 
however,  constant ;  the  other  lesions  are  variable. 

Symptoms. — The  more  marked  features  of  the  dis- 
ease are  found  among  the  motor  functions.  The  patient 
finds  a  difficulty  in  following  his  usual  occupation  on 
account  of  weakness,  which  may  be  noticed  first  in  the 
lower  or  upper  extremities,  usually  the  former.  After 
a  longer  or  shorter  time  this  weakness  increases  until 
there  is  paralysis ;  sometimes  one  limb  alone  is  at- 
tacked, or  both  arms  or  legs  may  be ;  at  length  the 
paralysis  extends  to  those  limbs  not  previously  affected. 
The  reflexes  are  diminished  and  lost  in  proportion  to 
the  severity  of  the  paralysis.    Inco-ordination  is  rare. 

When  time  enough  has  elapsed,  the  affected  muscles 
will  be  noticed  to  have  wasted,  unless,  as  occasionally 
happens,  the  increase  of  fat  conceals  the  atrophy,  or  a 


204  DISEASES  OF  TEE  SPINAL   CORD. 

sclerotic  degeneration  of  the  muscular  fibers  enables 
tliem  to  keep  their  size  while  losing  their  distinctive 
muscular  character ;  they  will  then  be  felt  as  hard  re- 
sisting masses. 

The  electrical  reactions  show  the  changes  due  to  de- 
generation of  nerves  and  muscles.  These  changes  will 
depend  somewhat  upon  the  progress  of  the  disease  and 
the  amount  of  structural  changes.  Yet  very  careful 
observations  made  by  Kahler  and  Pick  show  that  there 
is  no  absolute  relation  between  the  electrical  reactions 
and  the  loss  of  voluntary  power.  The  muscles  may 
show  reaction  of  degeneration,  yet  may  contract  under 
the  influence  of  the  will.  In  the  case  recorded  by  Kah- 
ler and  Pick  there  was  a  steady  diminution  of  the  f  ara- 
dic  contractility,  until  nearly  all  the  muscles  of  the 
limbs,  body,  and  face  were  thus  affected,  even  while 
the  voluntary  control  was  improving.  This  anomaly  is 
the  more  frequently  seen  during  restoration  of  the  mo- 
tor functions. 

The  progress  of  the  disease  may  be  arrested  at  any 
period ;  then,  after  an  interval,  either  the  symptoms 
may  be  aggravated  or,  more  frequently,  the  power  may 
slowly  return ;  occasionally  the  recovery  is  complete, 
more  frequently  it  is  only  partial. 

The  above  are  the  constant  and  essential  symptoms. 
Other  phenomena  depend  upon  what  other  parts  of  the 
cord  are  diseased. 

When  the  pain  is  severe,  there  is  probably  a  limited 
meningitis.  It  is  more  common  to  have  soreness  of  the 
muscles,  especially  before  any  aggravation  of  motor 
symptoms.  Numbness,  tingling,  and  a  sense  of  weari- 
ness may  precede  and  accompany  the  earlier  motor  dis- 
turbances. Cutaneous  sensibility  is,  as  a  rule,  only 
slightly  diminished,  and  is  often  not  affected. 

Patients  are  rarely  seen  at  the  very  co'  i.mencement 
of  the  disease,  so  that  the  symptoms  at  that  period  are 
only  occasionally  studied  ;  fever  is  sometimes  present, 
but  is  not  very  marked.     The  limbs  which  are  para- 


GHRONIG  ANTERIOR  POLIOMYELITIS.  205 

lyzed,  and  yet  more  if  atroiDliy  lias  set  in,  are  generally 
cold  and  may  be  cyanotic. 

The  bladder  and  rectum  are  rarely  affected.  There 
are  no  bed-sores.  The  ordinary  functions  of  digestion 
are  not  disturbed.  Cerebral  symptoms  are  absent,  ex- 
cept, in  a  few  instances,  nystagmus. 

Diagnosis. — It  is  scarcely  necessary  to  recapitulate 
the  symptoms  in  acute  anterior  poliomyelitis  for  the 
sake  of  diagnosis. 

It  is  quite  probable  that  formerly  chronic  anterior 
poliomyelitis  was  confounded  with  progressive  muscu- 
lar atrophy.  The  latter  is  more  slowly  progressive ; 
the  paralysis  or  weakness  appears  after  the  atrophy  or 
about  the  same  time ;  the  reaction  of  degeneration  is 
wanting  or  is  much  less  clearly  marked ;  the  reaction 
to  both  the  faradic  and  the  galvanic  currents  decreases, 
though  the  latter  may  persist  longer  than  the  former. 
In  the  progressive  atrophy  certain  muscles  are  attacked 
by  preference,  and  there  is  rather  an  irregularity  in  the 
progress  of  the  affection  ;  it  seems  to  Jump  from  one 
region  to  another,  leaving  intermediate  muscles  unaf- 
fected. There  is  less  likely  to  be  remissions  or  cures  ; 
the  reflexes  persist. 

Peognosis. — A  large  proportion  of  the  patients 
either  regain  a  certain  amount  of  motor  power,  or,  more 
rarely,  recover.     The  tendency  is  toward  remission. 

The  course  of  the  disease  is  long  and  slow,  and  years 
may  elapse  before  it  can  be  said  that  all  the  gain  pos- 
sible has  been  made. 

A  few  cases  of  death  have  been  recorded,  showing 
that  life  is  not  always  spared.  Of  course,  if  the  disease 
affects  the  medulla  oblongata  or  the  respiratory  centers, 
the  prognosis  must  be  unfavorable. 

Teeatment. — When  lead  seems  to  be  a  cause,  iodide 
of  potassium  should  be  given  at  once.  If,  after  a  week's 
use  of  that  drug,  lead  can  be  found  in  the  urine,  it  should 
be  continued  for  months.  Some  advise  large  doses  in 
order  to  eliminate  the  lead  quickly.     The  advantage  is 


206  DISEASES  OF  THE  SPINAL   CORD. 

doubtful ;  it  is  frequently  necessary  to  be  cautious  lest 
symptoms  of  acute  lead  -  poisoning  should  appear. 
Sometimes  one  or  two  grains  are  as  much  as  can  be 
given. 

Early  in  the  disease,  or  when  there  are  exacerba- 
tions, ergot  and  belladonna  may  be  given  as  in  acute 
myelitis. 

If  the  pain  is  severe,  morphia  or  atropia  may  be  ne- 
cessary, or  the  galvanic  current  may  be  found  sufficient 
to  relieve  the  pain. 

The  galvanic  current  should  be  applied  to  the  spine 
even  early  if  there  is  no  fever;  positive  pole  above, 
negative  below.  A  current  from  six  or  eight  cells,  such 
as  will  not  cause  discomfort,  can  be  used  daily,  or  every 
other  day,  for  five  minutes  at  a  time.  Later  the  para- 
lyzed muscles  should  be  stimulated  to  contraction  by 
the  direct  application  of  the  electrode  to  them,  the  cur- 
rent being  interrupted.  The  f  aradic  current  is  less  effi- 
cacious. 

Counter -irritation  to  the  back,  blisters,  dry  cups, 
or,  better  than  either,  the  actual  cautery,  may  be  of 
great  benefit. 

Rest  in  bed  while  the  disease  is  advancing  is  desir- 
able. If  its  progress  is  slow,  it  may  not  be  necessary, 
however,  to  stay  in  bed  all  the  time.  As  the  muscles 
are  regaining  power,  care  should  be  taken  not  to  over- 
tax them  by  too  prolonged  or  too  severe  use. 

Massage  and  warm  bathing,  not  too  warm,  are  use- 
ful adjuncts  as  a  means  of  maintaining  the  nutrition  of 
the  limbs. 


CHAPTER  XYII. 

PEOGEESSIVE  MTTSCFLAE  ATROPHY. 

Friedreich,  N.,  Ueber  progressive  Muskelatrophie.  Berlin, 
1873. — Charcot  et  Gombatjlt,  Note  sur  un  cas  d'atrophie  mus- 
culaire  progressive  spinale  protopathique.  Arch,  de  physiol., 
1875,  p.  736.— Sturge,  Allen.  Lancet,  May  21,  1881,  p.  828.— 
Fox,  A.  W.,  Case  of  Progressive  Muscular  Atrophy  with  Bulbar 
Paralysis.  Brit.  Med.  Jour.,  Jan.  15,  1881,  p.  82.— Clarke,  J.  L. 
Arch,  of  Med.,  London,  1863,  p.  l.—Med.  Chir.  Trans.,  1878,  p. 
103. 

ZBEMERLm,  Franz,  Ueber  hereditare  (tamiliare)  progressive 
Muskelatrophie.  Zeitschr.  f.  Tel.  Med.,  vii,  1883,  p.  15. — Erb,  W., 
Ueber  die  juvenile  Form  der  progressive  Muskelatrophie.  Deut. 
Arch.  f.  M.  Med.,  xxxiv,  1884,  p.  467. 

Three  theories  have  been  advocated  in  regard  to  the 
nature  of  this  disease  :  That  it  is  primarily  a  muscular 
affection,  the  changes  in  the  nervous  system  being  sec- 
ondary ;  that  it  is  a  disease  of  the  sympathetic  system  ; 
that  the  seat  of  the  disease  is  in  the  spinal  cord.  The 
question  as  to  which  of  these  is  the  correct  theory  has 
not  yet  been  settled,  and  I  have  not  the  data  upon 
which  to  form  a  iinal  opinion.  I  give  it  a  place  among 
lesions  of  the  spinal  cord  because  constant  changes  have 
been  found  in  the  cord,  and  because  it  seems  useful  to 
place  it  alongside  of  other  affections  which  somewhat 
resemble  it. 

Etiology. — As  the  first  symptoms  appear  gener- 
ally in  those  muscles  which  are  most  used,  it  is  proba- 
ble that  excessive  use  acts  as  one  cause,  at  least  as  the 
cause  for  localizing  the  disease  at  the  beginning. 

Men  are  more  frequently  attacked,  and  middle  adult 


208  DISEASES  OF  TEE  SPINAL   CORD. 

age  is  the  most  favorable  for  tlie  development  of  the 
disease. 

At  least  sometimes  heredity  seems  to  be  an  impor- 
tant setiological  factor. 

There  is  a  close  resemblance  between  progressive 
muscular  atrophy  and  pseudo-hypertrophic  paralysis, 
in  that  brothers  are  frequently  attacked,  and  the  dis- 
ease seems  to  be  transmitted  through  the  females  of  a 
family. 

Pathological  Anatomy. — Unfortunately,  it  is  im- 
possible to  give  a  satisfactory  account  of  the  post- 
mortem changes  connected  with  the  nervous  system, 
because  in  many  cases  the  examination  has  been  im- 
perfect. 

The  spinal  cord  has  been  frequently  found  either 
normal  or  with  very  slight  changes,  not  always  affect- 
ing the  cells.  In  some  of  the  cases  where  there  was  no 
change,  the  question  has  been  raised  whether  they  were 
cases  of  progressive  muscular  atrophy. 

In  a  large  number  of  cases  the  cells  of  the  anterior 
cornua  have  been  found  diseased,  atrophied. 

In  a  very  few  cases,  comparatively,  the  sympathetic 
has  been  found  diseased.  In  many  more  it  has  been 
examined  and  no  disease  found.  In  a  large  number  of 
cases,  even  where  the  cord  has  been  healthy,  the  sym- 
pathetic has  not  been  examined. 

The  weight  of  evidence  to  the  present  time  is  in 
favor  of  the  seat  of  the  disease  being  in  the  cord  ;  but 
it  is  necessary  that  more  examinations  should  be  made 
of  thoroughly  typical  cases  before  the  question  can  be 
decided. 

The  changes  in  the  muscles  are  only  occasionally  of 
an  active  nature  ;  they  are  rather  regressive  in  charac- 
ter. In  many  fibers  there  is  a  tendency  to  split  up  lon- 
gitudinally ;  much  less  frequently  they  separate  trans- 
versely. Frequently  there  is  a  simple  atrophy  ;  some- 
times a  waxy  degeneration  or  a  fatty  degeneration  can 
be  recoorni^ed. 


PROGRESSIVE  MUSCULAR  ATROPHY.  209 

Tlie  nuclei  of  tlie  muscles  may  be  increased  quite 
early,  and  sometimes  the  sarcolemma  sheath  is  filled 
with  these  nuclei  after  the  contractile  substance  of  the 
muscular  fiber  has  disappeared.  Finally  the  proper 
muscular  structure  disappears,  and  there  remains  only 
a  fibrous-like  substitute  in  place  of  the  muscle. 

An  increase  of  the  interstitial  tissue  with,  or  less 
commonly  without,  deposit  of  fat  may  proceed  uni- 
formly with  the  degeneration  of  the  muscles,  or  may 
even  advance  so  rapidly  as  to  give  the  muscles  an  ap- 
pearance of  having  undergone  hypertrophy. 

Symptoms. — The  atrophy  from  which  the  disease 
takes  its  name,  with  the  attending  weakness  and  pa- 
ralysis, is  the  principal  symptom.  The  wasting  is 
almost  or  quite  imperceptible  in  its  beginning,  pro- 
gresses very  slowly,  and  may  have  advanced  so  as  to 
seriously  interfere  with  the  use  of  the  limb  before  it  is 
noticed.  The  patient  is  aware,  perhaps,  for  a  short 
time  of  a  slight  loss  of  skill  or  readiness  in  his  motions, 
or  that  he  is  more  quickly  tired  than  usual ;  then  he 
finds  that  he  is  unable  to  use  his  hands  or  arms  with 
natural  ease  and  strength  ;  then  notices  the  change  in 
configuration,  and  may  think  the  whole  has  occurred 
vdthin  a  few  hours  ;  yet,  on  closely  questioning  him,  it 
will  be  discovered  that  several  weeks  at  least  have 
elapsed  since  the  first  slight  symptom  appeared. 

A  large  majority  of  patients  are  first  attacked  in  the 
hands  or  arms ;  usually  the  muscles  of  the  thenar  or 
hypothenar  eminence,  the  interossei  and  lumbricales, 
are  the  first  to  undergo  atrophy,  and  the  right  hand  or 
arm  is  much  the  more  frequently  affected  first.  Authors 
disagree  as  to  whether  the  atrophy  attacks  the  interos- 
sei or  the  muscles  of  the  thenar  eminence  first.  The 
position  of  the  fingers  is  peculiar  when  the  disease  has 
made  considerable  progress.  There  is  the  claw-shaped 
hand.  The  thenar  eminence  is  thinned,  leaving  a  flat- 
tened, slightly  concave  surface  in  place  of  the  normal 
convex  swelling  of  the  ball  of  the  thumb. 

14 


210  DISEASES  OF  TEE  SPINAL   CORD. 

Next  to  the  small  muscles  of  the  hand,  the  flexors 
and  supinators  of  the  forearm,  or  the  deltoid,  are  at- 
tacked ;  then  other  muscles  connected  with  the  scapula 
and  those  of  the  trunk,  and  finally  the  muscles  of  the 
lower  limbs,  may  be  affected.  The  progress  of  the  dis- 
ease from  muscle  to  muscle  observes  no  regular  order, 
but  muscles  widely  separated  may  be  attacked  before 
the  intermediate  muscles  suffer. 

Generally  both  sides  are  affected  nearly  at  the  same 
time,  though  often  several  days  or  weeks  elapse  before 
the  second  side  is  attacked.  The  rate  of  progress  dif- 
fers very  widely  ;  there  may  be  long  intervals  when  the 
symptoms  remain  stationary. 

Very  rarely  the  disease  may  begin  with  the  lower 
limbs — either  in  the  thighs  or  the  legs — though  Eulen- 
burg  thinks  this  form  occurs  only  among  children  in 
a  form  allied  to  pseudo-hypertrophic  paralysis. 

As  the  power  of  motion  is  not  lost  until  the  muscles 
have  almost  entirely  disappeared,  the  patient  may  be 
able  to  move  his  limbs  even  when  there  is  great  emacia- 
tion. When  the  atrophy  has  advanced  far,  so  that  a 
large  number  of  muscles,  both  those  of  the  limbs  and 
of  the  trunk,  are  greatly  wasted,  he  presents  a  pitiable 
appearance ;  especially  if  the  facial  muscles  have  also 
been  attacked ;  he  becomes  a  "walking  skeleton,"  the 
bones  apparently  only  covered  by  the  integument. 

Even  before  a  muscle  is  seen  to  waste,  and  while 
that  process  is  going  on,  very  slight  and  rapid  contrac- 
tions of  individual  muscular  fibers  can  be  seen,  which, 
occurring  repeatedly  in  the  same  or  adjoining  bundles 
of  fibers,  produce  what  is  called  fibrillari/  contractions. 
These  may  be  compared  to  the  fitful  flashing  sometimes 
seen  as  the  light  of  the  aurora  spreads  over  the  sky. 
If  these  contractions  do  not  appear  spontaneously,  they 
may  be  excited  by  giving  the  muscles  a  fillip  with  the 
finger  or  a  pencil.  By  observing  this  phenomenon  in 
muscles  not  yet  wasted,  it  is  often  possible  to  foretell 
which  vsdU  be  next  attacked. 


PROGRESSIVE  MUSCULAR  ATROPHY.  211 

The  electrical  reaction  of  both  nerves  and  muscles  is 
diminished  in  proportion  to  the  amount  of  atrophy. 
The  galvanic  current  will  cause  contractions  longer  than 
the  faradic  current.  Rosenthal  says  that  the  nerve- 
filaments  nearest  the  centers  may  react  normally,  while 
the  peripheral  ramifications  may  show  diminished  reac- 
tion, 

E-emak  discovered  that  when  the  negative  pole  is 
placed  over  the  fifth  or  sixth  cervical  vertebra,  and  the 
positive  pole  is  placed  on  the  side  of  the  neck  in  the 
carotid  fossa,  or  in  the  triangle  between  the  lower  jaw 
and  the  ear,  there  follow  contractions  in  the  atrophied 
muscles  on  the  side  opposite  that  where  the  positive 
pole  is  when  the  current  is  interrupted.  This  reaction 
is  most  easily  shown  with  the  galvanic  current,  but  it 
is  not  constant.  If  both  poles  are  placed  on  the  side  of 
the  neck,  with  a  weak  current,  the  contraction  may  be 
excited  on  both  sides.  Remak  called  this  "diplegic 
contraction."  He  referred  it  to  a  reflex  contraction  ex- 
cited through  the  medium  of  the  superior  cervical  gan- 
glion.    Others  do  not  agree  with  this  view. 

Sensibility  is  usually  not  affected ;  even  when  dis- 
turbed, the  change  is  very  slight.  Pain,  however,  in 
the  affected  muscles  is  not  uncommon ;  this  pain  may 
be  excited  by  motion  or  by  pressure,  and  it  is  some- 
times spontaneous.  Cutaneous  reflexes  are  sometimes 
heightened,  especially  in  the  early  stages.  The  patel- 
lar tendon  reflex  has  been  found  present  in  a  case 
where  the  muscles  of  the  legs  and  thighs  were  not  atro- 
phied ;  in  another  case  slightly  diminished.  It  is  some- 
times exaggerated,  its  strength  depending  upon  the 
state  of  the  muscles  which  contract  in  response  to  the 
stimulus. 

The  temperature  of  the  affected  limbs  is  sometimes 
at  first  moderately  elevated,  but  later  it  is  lowered. 
The  joints  may  be  swollen  and  painful,  more  particu- 
larly the  smaller  joints.  There  may  be  bed-sores  to- 
ward the  close,  unless  some  intercurrent  disease  short- 


212  DISEASES  OF  TEE  SPINAL   CORD. 

ens  life.  Occasionally  herpes  and  changes  in  the  hair 
and  nails  are  to  be  noticed. 

The  pupils  may  not  be  symmetrical,  and  there  may 
be  a  variation  in  their  relative  size,  but  in  very  many 
patients  there  is  no  deviation  from  the  normal  con- 
dition. 

The  disease  slowly  advances,  with  occasional  pauses, 
more  muscles  being  invaded,  until  the  patient  is  help- 
less. The  duration  may  extend  over  two  to  twenty 
years.  Finally  respiratory  muscles,  or  those  of  deglu- 
tition, are  affected,  and  the  patient  dies. 

Erb  describes  a  special  form  of  muscular  lesion, 
which  he  calls  the  "juvenile  form  of  progressive  mus- 
cular atrophy,"  consisting  in  part  of  hypertrophy  with 
subsequent  atrophy,  with  greater  or  less  formation  of 
fat  tissue  and  increase  of  interstitial  connective  tissue. 
The  same  sets  of  muscles  are  attacked  in  different  cases, 
especially  the  pectorales,  cucuUares,  latissimi,  flexor 
group  on  the  arm,  triceps ;  forearm  and  hand  are  not 
affected ;  in  the  lower  limbs,  those  of  the  thigh,  the 
peroneal  region,  and  the  calf  are  attacked ;  also  the 
lumbar  extensors.  There  is  no  fibrillary  tremor  nor 
degenerative  reaction.  The  disease  begins  in  childhood 
or  youth,  and  may  be  mistaken  for  progressive  muscu- 
lar atrophy  or  pseudo-hypertrophy. 

Peognosis. — There  is  no  immediate  danger  to  life 
unless  bulbar  symptoms  or  disturbed  respiration  set  in, 
but  the  prospect  of  cure  is  very  slight.  When  seen 
early,  it  may  be  that  the  disease  can  be  checked  and 
even  muscles  restored ;  but  this  is  very  rarely  the  result. 
As  a  rule,  there  is  before  the  patient  only  a  life  of 
gradually  increasing  weakness,  ending  in  total  disabil- 
ity, which  may  be  prolonged  through  years. 

DiAQNOSis. — The  disease  which  has  been  most  fre- 
quently confounded  with  progressive  muscular  atrophy 
is  poliomyelitis — anterior,  subacute,  or  chronic.  The 
commencement  and  progress  of  the  disease  are  much 


PROGRESSIVE  MUSCULAR  ATROPHY.  213 

more  gradual  in  the  former,  the  sensation  is  less  fre- 
quently disturbed  early  in  the  disease,  the  electrical 
reactions  are  different,  the  paralysis  is  more  propor- 
tionate to  the  atrophy,  except  when  there  is  increase 
of  fat,  and  the  irregular  order  in  which  the  muscles  are 
attacked  is  quite  characteristic.  In  many  cases  of  the 
chronic  anterior  poliomyelitis,  lead  is  found  to  be  a  fac- 
tor in  causing  the  disease ;  this  has  not  yet  been  recog- 
nized in  progressive  muscular  atrophy,  though  it  was 
found  in  one  of  my  patients. 

Local  injuries  to  both  muscles  and  nerves  may  simu- 
late progressive  muscular  atrophy,  and  wasting  of  mus- 
cles in  consequence  of  Joint  disease  may  lead  at  first  to 
doubt  as  to  diagnosis,  but  careful  study  of  the  history 
and  of  all  the  circumstances  will  probably  guard  one 
from  mistake. 

The  local  paralysis  of  the  hands  from  lead,  the  wrist- 
drop seen  in  that  affection,  can  be  recognized  by  the 
fact  that  the  extensors  are  chiefly  affected,  and  the  in- 
terossei  and  the  muscles  of  the  thenar  eminence  escape ; 
the  fact  of  exposure  to  lead,  previous  lead  colic,  the 
lead  cachexia,  and  the  condition  of  the  blood,  would  aid 
in  diagnosis.  Yet  once  in  a  great  while  a  case  may 
occur  which  will  require  great  care  to  decide  correctly. 

Teeatmeistt. — Internal  remedies  are  not  likely  to  be 
of  much  value.  If,  however,  lead  can  be  detected  in 
the  system,  an  effort  should  be  made  to  eliminate  it  by 
using  iodide  of  potassium. 

Electricity  is  of  value — either  the  faradic  or  galvanic 
current — applied  locally,  so  as  to  cause  muscular  con- 
tractions ;  that  current  is  to  be  chosen  which  will  most 
readily  cause  the  muscles  to  contract ;  sometimes  a  very 
strong  current  will  be  needed.  The  galvanic  current, 
of  moderate  strength,  may  be  applied  to  the  spine  at 
the  same  time. 

Exercise  should  be  restricted  within  the  limits  of 
fatigue.  Patients  are  mistaken  in  supposing  that  by 
taking  much  exercise  they  can  restore  the  strength  of 


214:  DISEASES  OF  THE  SPINAL   COED. 

diseased  muscles.  It  is  necessary  to  caution  th.em  on 
this  point.  When  the  muscular  power  is  much  re- 
duced, and  even  before,  Swedish  movement  is  of  value. 
Massage  should  be  used  from  the  beginning  where  it  is 
practicable. 

These  means  for  help  should  be  used  perseveringly 
through  many  months  before  discontinuing  treatment. 
No  benefit  can  be  expected  from  a  short  treatment. 


CHAPTER  XVIII. 

BULBAE  PAEALYSIS  (LABIO-GLOSSO-LAEYNGEAL  PAEALY- 

sis). 

KUSSMAUL,  A.,  Ueber  die  fortschreitende  Bulbarparalyse  und 
ihr  Verhaltniss  zur  progressiven  Muskelatrophie.  Volkmann's 
kl.  Vortrdge,  No.  54,  1873. — Strumpell,  Adolf,  Zur  Casuistik 
der  apoplektische  Bulbarlahmungen.  Deut.  Arch.  f.  Jcl.  Med., 
xxviii,  1880,  p.  43.— Beevor,  C.  E.,  Case  of  Glosso-labial  Paralysis 
with  Progressive  Muscular  Atrophy  and  Lateral  Sclerosis.  Brain, 
Oct.,  1882,  p.  403. — Leyden,  E.,  Zur  progressiven  Bulbarparalyse. 
Arch.  f.  Psych,  u.  NervenJcr.,  ii,  iii. — Finny,  J.  M.,  Clinical  Re- 
marks on  Cases  illustrating  the  Essential  Identity  of  Progressive 
Muscular  Atrophy  and  Progressive  Bulbar  Paralysis.  Brit.  Med. 
Jour.,  June  14,  1884,  p.  1132.— Bennett,  A.  H.,  Bulbo-spinal 
Atrophic  Paralysis.  Brit.  Med.  Jour.,  March  8,  1884,  p.  647. — 
Eisenlohr,  C.  ,  Ueber  acute  Bulbar-  und  Ponsaff ectionen.  Arch, 
f.  Psych,  u.  Nervenhr.,  ix,  p.  1,  x,  p.  31. — Ross,  James,  Labio- 
glosso-pharyngeal  Paralysis  of  Cerebral  Origin.  Brain,  1882,  p. 
145. — KiRCHHOFF,  Cerebrale  Glosso  -  Pharyngo  -  Labial  -  Paralyse 
mit  einseitigem  Herd.  Arch.  f.  Psych,  u.  NervenJcr.,  xi,  1880,  p. 
132. 

BULBAR  PARALYSIS. 

Duclieiiiie  first  caUed  attention  to  the  combination 
of  symptoms  whicli  are  known  as  bulbar  paralysis  un- 
der the  name  of  glosso-labio-laryngeal  paralysis.  There 
is  paralysis  of  the  muscles  with  atrophy  of  the  tongue, 
of  the  soft  palate,  of  the  lips,  of  the  pharynx  and  lar- 
ynx ;  muscular  atrophy  may  also  extend  to  other  re- 
gions, until  with  the  symptoms  of  bulbar  paralysis 
there  are  united  those  of  progressive  muscular  atrophy. 

Pathological  Anatomy. — Muscles  undergo  the 
changes  which  are  found  in  other  cases  of  atrophy. 
The  nerves,  especially  the  hypoglossal,  facial,  and  ac- 


216  DISEASES  OF  THE  SPINAL   CORD. 

cessory,  exhibit  the  usual  appearances  of  fatty  degen- 
eration, such  as  are  found  in  other  cases  of  muscular 
atrophy  of  central  origin. 

The  medulla  oblongata  seems  to  be  the  primary  seat 
of  the  disease.  Often  nothing  abnormal  can  be  recog- 
nized with  the  naked  eye ;  but  under  the  microscope 
changes  will  be  discovered  in  the  motor  nuclei  of  the 
medulla.  The  ganglion  nerve-cells  undergo  degenera- 
tion and  atrophy  either  with  or  without  disease  of  the 
surrounding  tissues.  The  nuclei  of  the  hypoglossal, 
accessory,  vagus,  and  that  part  of  the  facial  nucleus 
connected  with  its  inferior  branch,  are  most  frequently 
aJBfected ;  the  nucleus  of  the  glosso-pharyngeal  nerve  is 
less  frequently  affected.  When  the  disease  spreads  so 
as  to  implicate  the  muscles  of  the  extremities,  the  cor- 
responding parts  of  the  spinal  cord  will  also  be  found 
affected. 

Etiology. — Of  the  causes  of  bulbar  paralysis  we 
know  almost  nothing.  It  is  confined  almost  entirely 
to  advanced  life,  and  is  more  frequent  among  males ; 
but  it  has  been  seen  as  early  as  twelve  years  ;  Erb  saw 
it  in  a  girl  of  twenty  years.  Syphilis,  exposure  to  cold, 
and  injuries  have  been  mentioned  as  causes. 

Symptoms. — As  with  most  chronic  diseases  of  the 
spinal  cord,  the  earliest  symptoms  are  so  insignificant 
as  to  be  often  overlooked  or  neglected. 

They  vary  in  different  cases  according  as  the  nucleus 
of  one  or  another  of  the  nerves  of  the  medulla  oblon- 
gata is  chiefly  or  primarily  affected.  The  hypoglossal 
nucleus  generally  suffers  first,  and  in  the  majority  of 
cases  the  first  motor  disturbance  is  noticed  in  the 
tongue.  The  patient  is  not  able  to  move  his  tongue 
quite  as  freely  as  normal,  and  his  articulation  becomes 
imperfect.  Some  letters  can  not  be  readily  pronounced  ; 
e  is  first  lost,  then  there  is  trouble  in  expressing  the 
sounds  r,  sh,  s,  I,  7c,  g,  t,  and  later  d  and  n ;  the  mo- 
tions of  the  tongue,  apart  from  speech,  are  interfered 
with,  and  it  can  not  be  protruded  beyond  the  teeth ; 


BULBAR  PARALYSIS.  21T 

the  affection  being  bilateral,  it  is  not  protruded  to  one 
side,  it  is  riot  moved  forward,  it  can  not  be  turned  in 
the  mouth  to  loosen  food  from  between  the  gums  and 
cheek,  and  it  can  not  be  formed  with  a  trough-like  de- 
pression in  the  center  ;  the  tip  can  not  be  raised  against 
the  upper  teeth,  and  the  center  or  root  of  the  tongue 
can  not  be  arched  to  touch  the  hard  and  soft  palate ;  it 
can  not  be  used  to  press  food  backward  in  the  first  act 
of  deglutition. 

When  the  nucleus  for  the  lower  branch  of  the  facial 
nerve  is  affected,  the  lips  act  less  readily,  and,  if  the 
disease  begins  thus,  the  letters  in  which  the  lips  chiefly 
act  are  first  pronounced  indistinctly ;  if  the  lips  are 
affected  later,  then  the  power  to  pronounce  those  letters 
is  lost  later ;  these  letters  are  o  and  u  first,  later  e  and 
a ;  of  the  consonants,  p  and  f ;  later  5,  m,  and  li  are 
lost.  When  the  lips  can  not  be  readily  moved,  there 
is  much  difficulty  in  keeping  food  in  the  mouth  while 
eating ;  the  saliva  runs  out  of  the  mouth. 

When  the  soft  palate  is  paralyzed,  which  is  only 
after  the  tongue  or  lips  have  been  affected,  the  voice 
acquires  a  nasal  tone,  and  the  explosives  can  not  be 
clearly  pronounced,  especially  5  and  jp.  If  the  loss  of 
power  in  the  soft  palate  is  considerable,  drinks  will  re- 
turn through  the  nose,  and,  if  it  is  extreme,  even  solid 
food  will  thus  return.  The  glottis  is  not  properly 
closed,  and  therefore  food,  or  more  especially  drink, 
enters  and  excites  paroxysms  of  coughing.  The  pa- 
tient gradually  gives  up  drinking  and  tries  to  swallow 
only  soft  solids. 

The  patient's  countenance  acquires  a  characteristic 
expression ;  from  the  paralysis  of  the  lower  branches 
of  the  facial  nerve  the  mouth  and  lower  part  of  the  face 
are  motionless  ;  the  lower  lip  is  dragged  down  and  rolls 
outward  from  its  own  weight ;  the  saliva  acquires  a 
more  tenacious  character,  and,  not  being  swallowed, 
collects  and  flows  out  at  the  corners  of  the  half-open 
mouth.     The  tongue  can  not  be  protruded  nor  moved, 


218  DISEASES  OF  TEE  SPINAL   CORD. 

but  lies  on  the  floor  of  the  mouth,  atrophied  and 
shrunken,  constantly  agitated  by  fine  fibrillary  tre- 
mors. The  superior  branch  of  the  facial  nerve  is  not 
paralyzed,  and  hence  the  forehead  and  eyelids  move 
naturally.    The  ocular  muscles  are  unaffected. 

Sensation  is  not  disturbed,  nor  are  the  special  senses, 
taste  remaining  intact. 

The  disease  advances  slowly,  sometimes  with  remis- 
sions, but  as  a  rule  steadily,  until  the  patient  at  last  is 
a  pitiable  spectacle,  talking  with  extreme  diflficulty^ 
perhaps  unable  to  make  himself  understood ;  intelli- 
gent, conscious  of  his  condition,  with  bright  and  speak- 
ing eyes,  he  eagerly  desires  the  food  which  he  can  not 
swallow,  or,  if  he  tries  laboriously  to  swallow,  is  nearly 
strangled  by  choking.  He  necessarily  becomes  weak 
and  emaciated  from  lack  of  nutrition ;  but,  apart  from 
this  cause  of  debility,  it  is  not  infrequent  that  the  mus- 
cles of  the  extremities  and  even  of  the  trunk  suffer 
atrophy,  as  the  disease  of  the  motor  cells  extends  to 
those  in  the  anterior  cornua  of  the  cord ;  thus  general 
muscular  atrophy  is  added  to  the  local.  The  arms  and 
neck  are  usually  first  the  seat  of  this  change. 

The  pulse  is  sometimes  irregular  or  rapid,  and  there 
may  be  dyspnoea,  especially  toward  the  close  of  life ; 
coughing  and  sneezing  become  impossible. 

Life  may  be  cut  short  by  disease  of  the  lungs,  ex- 
cited by  the  entrance  of  food  into  the  bronchi,  or  by 
suffocation  during  an  attack  of  dyspnoea,  or  more  slow- 
ly by  starvation. 

The  atrophy  and  paralysis  are  attended  with  changes 
of  electrical  reaction  in  the  affected  muscles,  such  as  are 
found  in  progressive  muscular  atrophy.  The  faradic 
reaction  may  seem  to  have  suffered  little,  as  many  mus- 
cular fibers  remain  without  atrophy,  though  at  a  late 
stage  it  will  be  diminished ;  but  the  galvanic  current 
will  show  the  reaction  of  degeneration  when  the  disease 
has  advanced  somewhat. 

Not  only  the  tongue,  but  the  other  affected  muscles, 


BULBAR  PARALYSIS.  219 

may  be  the  seat  of  fine  fibrillary  tremors,  snch  as  are 
seen  in  progressive  muscular  atrophy. 

N'atuee  of  the  Disease. — The  nature  of  the  atro- 
phy and  paralysis  in  bulbar  paralysis,  and  its  relation 
or  connection  with  progressive  muscular  atrophy,  has 
been  the  subject  of  controversy.  In  both  diseases  there 
is  the  same  combination  of  symptoms,  making  allow- 
ance, of  course,  for  the  difference  of  function  in  the 
different  muscles.  There  is  diminished  skill  or  facility 
in  the  execution  of  movements,  a  slight  paralysis,  which 
gradually  increases  in  degree  ;  at  length  atrophy  is  no- 
ticed, but  not  until  so  much  of  the  muscular  structure 
has  degenerated  as  to  cause  the  loss  of  function  to  be 
prominent ;  fibrillary  tremor ;  change  of  electrical  re- 
action when  so  much  of  the  muscle  is  affected  that  the 
change  can  be  recognized;  the  disease  progresses  to 
finally  almost  entire  and  absolute  paralysis  ;  in  both, 
sensation  is  very  rarely  disturbed ;  the  destruction  of 
the  large  motor  cells  in  the  nuclei  of  the  cranial  nerves 
and  the  anterior  cornua  in  the  cord  is  the  same  in  na- 
ture, so  far  as  our  means  of  examination  enable  us  to 
judge. 

Besides  these  points  of  correspondence,  the  two  dis- 
eases run  into  each  other.  Before  bulbar  paralysis 
ends  in  death,  it  is  usual  to  see  the  limbs  affected  with 
muscular  atroj)hy ;  and  often,  in  progressive  muscular 
atrophy,  bulbar  symptoms  appear  near  the  close  of 
Hfe. 

The  two  affections  may,  then,  be  justly  looked  upon 
as  pathologically  one  disease,  as  clinically  distinct  only 
because  of  the  wide  difference  in  the  function  of  the 
parts  innervated  by  the  regions  affected  in  the  cord  and 
medulla. 

In  very  many  cases,  at  the  autopsy  it  has  been  found 
that  the  pyramidal  tracts  in  the  lateral  and  even  in  the 
anterior  columns  were  altered.  In  some  of  these  cases 
the  exaggerated  reflexes  of  lateral  sclerosis  were  recog- 
nized during  life.     It  is  as  yet  doubtful  whether  this  is 


220  DISEASES  OF  THE  SPINAL   CORD. 

to  be  considered  as  a  secondary  degeneration  and  com- 
plication, or  whether  the  few  cases  of  this  character 
are  to  be  classed  as  amyotrophic  lateral  sclerosis. 

Diagnosis. — Especially  in  the  early  stage  it  will  re- 
quire a  careful  examination  of  all  the  symptoms  to 
recognize  the  disease ;  similar  symptoms  may  be  seen 
in  the  early  stages  of  general  paralysis ;  then  the  vari- 
ation in  pupils,  the  general  weakness  of  the  limbs,  the 
tremor,  and  the  mental  condition  of  the  patient,  may  aid 
in  diagnosis,  but  sometimes  it  will  be  necessary  to  wait 
for  further  developments.  When  the  disease  is  well 
advanced  it  can  hardly  be  mistaken,  yet,  if  a  patient  is 
seen  in  an  advanced  stage,  without  having  a  knowledge 
of  the  history  of  the  origin  and  progress  of  the  symp- 
toms, it  may  be  very  difficult  to  decide  whether  it  is 
the  chronic  or  acute  bulbar  paralysis. 

Pkogjstosis. — There  is  no  case  on  record  of  recovery 
in  uncomplicated,  primary  bulbar  paralysis.  All  the 
instances  of  recovery,  if  carefully  examined,  will  be 
seen  to  have  presented  bulbar  symptoms  as  secondary 
only.     The  prognosis  is,  therefore,  unfavorable. 

When  the  significance  of  the  peculiar  early  symp- 
toms is  generally  recognized  in  the  profession,  so  that 
treatment  can  be  commenced  early,  a  more  favorable 
result  may  be  obtained. 

Remissions  of  longer  or  shorter  duration  are  not  un- 
common, as  in  all  chronic  and  slowly  progressive  dis- 
eases. The  duration  of  the  disease  is  only  a  few  years  ; 
Erb  says  from  one  to  five. 

Teeatment. — It  is  certainly  rather  discouraging  to 
consider  that  no  treatment  has  as  yet  been  successful. 
Electricity  is  the  most  promising,  and  may,  for  a  short 
time  at  least,  contribute  to  the  comfort  of  the  patient ; 
it  may  render  swallowing  less  difficult.  The  galvanic 
current  should  be  used.  It  may  be  passed  from  one 
mastoid  to  the  other,  keeping  the  electrodes  in  one 
place  ;  Erb  also  recommends  galvanization  of  the  cervi- 
cal sympathetic  (anode  on  the  back  of  the  neck,  cathode 


BULBAR  PARALYSIS.  221 

at  the  angle  of  the  lower  jaw).  The  electrodes  may  be 
applied  to  the  sides  of  the  neck  so  as  to  excite  the  mus- 
cles of  deglutition,  and  to  stimulate  the  recurrent  laryn- 
geal nerve,  using  the  faradic  and  galvanic  current  alter- 
nately. As  the  muscles  are  weak,  having  undergone 
partial  atrophy,  they  are  easily  tired,  therefore  the  ap- 
plication should  be  short — three  to  five  minutes ;  this 
may  be  repeated  daily,  or  every  other  day.  The  treat- 
ment by  electricity  should  be  persevered  with  for  sev- 
eral months. 

Counter-irritation,  by  means  of  dry  cups,  blisters, 
or  cautery,  has  been  recommended  ;  also  hydrotherapy 
is  advised.  All  these  means  may  be  employed,  at  least 
with  the  advantage  of  making  the  patient  more  con- 
tented. 

Erb  says  that  medicines  taken  internally  have  never 
produced  the  very  faintest  effect.  Still,  he  recommends 
the  trial  of  nitrate  of  silver,  iodide  of  potassium,  iodide 
of  iron,  chloride  of  gold  and  sodium,  ergotin,  bella- 
donna, etc. 

The  most  important  part  of  treatment  is  the  general 
care  of  the  patient.  The  general  health  is  to  be  cared 
for  by  regulating  the  habits ;  too  prolonged  exercise 
fatigues  and  exhausts,  therefore  injures  the  patient, 
especially  after  the  muscles  of  the  limbs  are  affected. 
If  efforts  to  converse  are  continued  too  long,  they  ex- 
haust the  muscles  of  the  throat.  The  food  should  be 
soft,  so  as  to  require  very  little  mastication,  and  be- 
cause soft  solids  are  most  readily  swallowed.  The  pa- 
tient should  be  fed  slowly,  time  enough  being  allowed 
for  the  partially  atrophied  muscles  to  rest.  It  may  be 
well  to  increase  the  number  of  meals  during  the  day. 
Finally,  it  may  be  necessary  to  feed  the  patient  through 
a  tube  introduced  into  the  stomach. 

When  dyspnoea,  or,  as  patients  sometimes  describe 
it,  "attacks  of  asthma,"  occur,  sedatives,  narcotics,  and 
stimulants,  internally  or  by  inhalation,  or  subcutane- 
ously,  must  be  used. 


222  DISEASES  OF  THE  SPINAL   CORD. 

ACUTE  BULBAR  PARALYSIS. 

Many  cases  liave  been  reported  in  whicli  the  symp- 
toms of  bulbar  paralysis  liave  appeared  suddenly, 
witliout  the  progressive  character.  Such  cases  may  be 
considered  as  acute,  and  may  be  so  called  if  we  keep 
in  mind  that  they  are  due  to  pathological  changes  quite 
different  from  those  found  in  the  progressive  disease. 

Etiology.  —  The  causes  of  the  combination  of 
symptoms  in  these  acute  cases  are:  softening  due  to 
plugging  of  vessels  by  a  thrombus  or  an  embolus ; 
haemorrhage  ;  acute  inflammation  ;  tumors  ;  and,  in  a 
few  cases,  cerebral  lesions.  The  causes  of  the  acute 
form  would  then  be  those  that  would  give  rise  to  the 
above  pathological  conditions. 

Symptoms. — The  symptoms  vary  considerably  from 
those  found  in  the  chronic  cases.  The  onset  of  the  dis- 
ease is  sudden,  the  paralysis  reaching  its  height  in  a 
few  hours,  or  at  most  a  few  days.  Convulsions  of  an 
epileptiform  character  may  be  among  the  earlier  symp- 
toms. After  the  first  attack  there  may  be  a  slight  im- 
provement or  a  remission,  and  afterward  a  steady  pro- 
gression in  the  disease. 

Besides  the  bulbar  symptoms  due  to  lesion  of  the 
nerves  of  the  medulla  or  their  nuclei,  there  will  proba- 
bly be  also  a  rapidly  occurring  paralysis  of  the  limbs, 
and  sensation  may  be  affected,  as  it  is  not  in  the  chron- 
ic form.  The  paralytic  symptoms  may  extend  so  as  to 
show  that  parts  anterior  to  the  bulb  are  affected ;  also 
the  paralysis  of  the  limbs  may  be  unilateral  and  alter- 
nate— ^i.  e.,  on  the  side  opposite  to  that  on  which  the 
cranial  nerves  are  affected.  In  cases  of  acute  inflam- 
mation of  the  medulla,  such  as  has  been  reported  by 
Leyden,  the  symptoms  appear  less  suddenly  than  in 
haemorrhage  or  in  occlusion  of  vessels,  but  they  are 
developed  in  a  comparatively  short  time,  and  other 
than  bulbar  symptoms  appearing  with  them  will  aid  in 
forming  a  correct  diagnosis. 


ACUTE  BULBAR  PARALYSIS.  223 

Several  times  clearly  marked  bulbar  phenomena 
have  been  seen  where  the  lesion  was  entirely  cerebral ; 
this  has  been  noticed  where  the  lesion  has  been  multi- 
ple, affecting  both  sides  of  the  brain  :  but  bulbar  symp- 
toms have  also  been  found  where  the  cerebral  lesion 
has  been  unilateral. 

The  diagnosis  of  the  nature  of  the  process  giving 
rise  to  acute  bulbar  paralysis  must  be  made  from  a 
consideration  of  the  circumstances  attending  the  at- 
tack :  on  the  same  principles  as  will  aid  in  forming  a 
diagnosis  in  other  cases  of  cerebral  lesion.  These  need 
not  be  reviewed  here. 

The  prognosis  of  acute  bulbar  paralysis  is  not  so  se- 
rious as  of  the  progressive.  Eisenlohr  has  reported  re- 
coveries in  several  cases.  Striimpell  reports  a  case  of 
recovery.  Erb  reports  favorable  results  in  a  case  of 
seven  months'  duration. 

The  insidious,  unpretending,  progressive  disease, 
which  seems  so  much  milder,  and  at  first  insignificant, 
is  much  the  more  dangerous  and  fatal. 

The  treatment  must  depend  upon  the  nature  of  the 
pathological  process.  Iodide  of  potassium  is  indicated 
if  there  is  reason  to  suspect  an  occlusion  of  arteries, 
especially  if  there  has  been  syphilis ;  also  if  there  is 
possibly  a  syphilitic  thickening  of  the  membranes. 
Erb  passed  a  current  from  eight  cells  through  the  head 
from  one  mastoid  process  to  the  other ;  and  also  galvan- 
ized the  cervical  sympathetic. 


CHAPTEE  XIX. 

LOCOMOTOR  ATAXIA. 

TABES  DORSALIS.— POSTERIOK  SPINAL  SCLEROSIS. 

Trousseau,  A.,  Clinique  medicale  de  I'Hotel-Dieu  de Paris,  t.  ii. 
— ^EiSENMANN,  Die  Bewegungs-Ataxie.  Wien,  1863. — Buzzard, 
T.,  On  Articular  and  Osseous  Lesions  in  Locomotor  Ataxia.  Med. 
Times  and  Gaz.,  Feb.  14,  1880  ;  Brit.  Med.  Jour.,  March  5,  1881. 
— ^Williams,  J.  A. ,  Remarks  upon  tlie  Osseous  Lesions  of  Loco- 
motor Ataxia.  Lancet,  Dec.  9,  1883,  p.  977.— Fere,  Ch.,  Descrip- 
tion de  quelques  pieces  relatives  aux  lesions  osseuses  et  articulaires 
des  ataxiques.  Arch,  de  neurol.,  iv,  1883,  p.  303. — Lecoq,  Etudes 
sur  les  accidents  apoplectif ormes  qui  peuvent  compliques  le  debut, 
le  cours,  la  fin  de  I'ataxie.  Bev.  de  med..  No.  6,  1883. — Gee,  Lo- 
comotor Ataxia  associated  with  Perforating  Ulcer  of  the  Foot. 
St.  Barthol.  Hosp.  Rep.,  xviii,  1883.  —  Friedreich,  N.,  Ueber 
Ataxic  mit  besonderer  Beriicksichtigung  der  hereditaren  Formen. 
Virch.  Arch.,  Bd.  36,  37,  68,  70.— Johnston,  Nerve-Stretching. 
Brit.  Med.  Jour.,  Jnlj  2,1881. — Bastian.  Ibid. — Spencer.  Ibid., 
Jan.  38, 1883. — Lamont.  Lancet,  Jan.  6, 1883.— Seguin,  E.  C,  On 
the  Early  Diagnosis  of  some  Organic  Diseases  of  the  Nervous  Sys- 
tem. Med.  Record,  Feb.  26,  1881,  p.  335.— VoiGT,  Syphilis  with 
Ataxia.  Berl.  M.  Wochenschr.,  1881. — Erb.  Cbl.  f.  Nervenhk., 
Psych.,  etc.,  Aug.  15,  1881.— Reumont.  Ibid.,  Sept.  1,  1881.— 
Gowers.  Lancet,  Jan.  15,  1881. — Abadie.  Gaz.  Hebd.,  Dec.  1, 
1883. — Buzzard.  Lancet,  June  10,  1883.— Weber,  Leonard. 
Med.  News,  March  39,  1884.— Seguin,  E.  C.  Arch,  of  Med., 
Aug.,  1884. 

Pathological  Aistatomy. — In  the  fresh  state,  to 
the  naked  eye,  the  posterior  columns  will  be  seen  to 
have  a  semi- translucent  appearance.  This  change  may 
affect  the  whole  of  the  posterior  columns,  where  the 
disease  has  been  long  present,  generally  in  the  lumbar 
region ;  where  the  lesion  is  recent,  only  the  external 


LOCOMOTOR  ATAXIA.  225 

radical  columns,  the  posterior  root-zones,  are  affected ; 
and  in  its  earliest  periods  the  change  of  structure  is 
found  near  the  posterior  cornua,  not  quite  touching 
them  and  not  quite  reaching  the  periphery  of  the  cord. 
This  change  of  color  in  rare  cases  extends  to  the  direct 
cerebellar  tracts. 

The  disease  is  commonly  most  extensive  in  the  lum- 
bar enlargement,  where  it  usually  begins ;  sometimes 
the  cervical  enlargement  is  first  attacked.  At  whatever 
level  the  disease  is  found,  it  is  situated  in  the  posterior 
root-zones,  or  in  corresponding  parts  in  the  medulla. 
Above  the  medulla  the  locality  of  the  lesion  has  not 
been  made  out.  The  central  parts  of  the  posterior  col- 
umns— columns  of  Goll— are  affected  secondarily. 

The  pia  mater  covering  the  part  of  the  cord  affected 
may  be  thickened  and  somewhat  adherent. 

After  hardening  in  some  chromic  solution,  the  dis- 
eased parts  acquire  a  yellowish  color,  distinct  from  the 
darker  color  of  the  healthy  parts. 

Under  the  microscope  it  v^dll  be  found  that  the  nerve- 
fibers  have  undergone  change ;  they  have  lost  their  med- 
ullary sheaths,  and  are  reduced  to  their  axis  cylinders. 
Sometimes  the  axis  cylinders  are  slightly  hypertro- 
phied.  The  neuroglia  has  increased.  This  gives  the 
cord  its  translucent  appearance.  When  a  section  is 
stained  by  carmine,  the  diseased  part  is  more  intensely 
colored. 

The  nerve-fibers  are  not  all  destroyed  in  any  area, 
except  in  a  very  advanced  stage  of  the  disease,  and 
groups  of  nearly  healthy  fibers,  or  single  ones,  are 
found  scattered  irregularly  through  the  altered  por- 
tions. 

Corpora  amylacea  are  seen  thickly  scattered  through 
the  affected  regions. 

Granular  corpuscles  may  be  rather  numerous  in 
early  stages  of  the  disease,  but  are  less  in  number  in 
the  more  advanced  stages. 

The  walls  of  the  vessels  are  thickened. 

15 


226  DISEASES  OF  TEE  SPINAL   CORD. 

Tlie  nerve-cells  of  the  anterior  cornua  are  degener- 
ated in  those  cases  where  muscular  atrophy  occurs ; 
they  have  also  been  found  affected  in  several  cases  of 
articular  and  osseous  lesions. 

Etiology. — By  far  the  larger  number  of  patients 
are  men,  comparatively  few  being  women  ;  children  are 
only  rarely  affected.  The  age  at  which  the  first  symp- 
toms are  generally  noticed  is  between  twenty-five  and 
forty-five  years.  Heredity  is  thought  by  some  to  act 
as  a  predisposing  cause ;  excess  in  the  use  of  alcoholic 
liquors,  and  acute  diseases,  are  also  predisposing 
causes. 

Exposure  to  cold,  especially  to  cold  combined  with 
wet,  is  one  of  the  most  frequent  exciting  causes.  Over- 
exertion, excessive  labor,  especially  on  the  feet,  are 
other  frequent  causes  of  the  disease ;  hence,  the  larger 
number  of  patients  are  to  be  found  among  those  whose 
occupation  requires  them  to  stand  or  walk  nearly  all 
the  time,  whose  feet  are  much  exposed  to  cold  and  wet. 

Lately  the  connection  of  syphilis  with  locomotor 
ataxia  has  attracted  much  attention.  A  very  large  pro- 
portion of  ataxics  are  found  to  have  had  syphilis  in 
early  life,  more  than  half  of  these  to  have  had  second- 
ary symptoms  ;  very  many  have  never  had  these.  Erb 
assigns  much  importance  to  this  relation  between  the 
two  diseases.  Gowers  seems  to  count  syphilis  as  a  pre- 
disposing cause.  "  It  seems,"  he  says,  "  that  one  effect 
of  constitutional  syphilis  may  be  to  induce  a  neuro- 
pathic state  in  which  certain  degenerative  diseases  of 
the  nervous  system  readUy  occur."  The  proportion 
of  ataxics  who  have  had  syphilis  seems  to  be  less  in 
America  than  in  Europe. 

Whatever  connection  there  may  be,  or  if  there  is 
none,  it  is  an  interesting  fact  that  from  forty -five  per 
cent  to  eighty-eight  per  cent  of  ataxics  are  found  to 
have  had  syphilis. 

Venereal  excesses  are  generally  considered  as  one  of 
the  causes  of  locomotor  ataxia.     Many  times  such  ex- 


LOCOMOTOR  ATAXIA.  22T 

cesses  must  be  reckoned  among  the  early  symptoms  of 
the  disease. 

Injuries,  as  Jar  or  concussion  of  the  spine,  have 
sometimes  seemed  to  be  the  cause  of  ataxia.  Cases  in 
which  such  a  relation  can  be  traced  are,  however,  rare. 

Symptoms. — The  earliest  and  most  extensive  changes 
in  the  cord  are  found  in  those  regions  which  are  act- 
ive in  transmitting  sensation ;  the  earliest  symptoms 
of  the  disease  are  perverted  sensations ;  and,  as  the 
changes  are  found  throughout  the  whole  length  of  the 
cerebro-spinal  axis,  commencing  at  any  level,  it  may 
be  expected  that  the  symptoms  would  show  a  great  va- 
riety both  in  the  beginning  and  during  the  course  of 
the  disease.    This  is  the  case. 

The  earliest  symptom  is  pain,  which  is  thought  to 
be  rheumatic  or  neuralgic,  and  no  inquiry  made  as  to  its 
nature  or  cause.  In  most  cases  the  pain  is  in  the  legs 
or  feet.  If  the  upper  part  of  the  cord  is  first  affected, 
it  may  be  first  felt  in  the  arms,  or  may  follow  the  course 
of  the  occipital  nerve  over  the  back  of  the  head ;  once 
in  a  while  the  fifth  nerve  is  affected,  and  the  pain  is 
felt  in  the  face.  The  pain  is  peculiar  in  character  ;  it 
is  of  a  stabbing,  cutting  nature,  deep-seated  rather 
than  superficial,  as  if  in  the  muscles  or  bones ;  each 
stab  is  of  only  momentary  duration,  and  is  no  sooner 
felt  than  it  is  gone ;  these  darts  of  pain  succeed  one 
another  in  rapid  succession,  or  may  be  separated  by  a 
short  interval. 

The  attacks  may  continue  several  minutes  or  hours, 
commencing  without  warning,  and  as  suddenly  ceasing. 
At  first  they  are  not  of  frequent  occurrence,  but  as 
time  goes  on  they  recur  at  shorter  intervals.  Some- 
times an  aching  or  tired  sensation  is  noticed  between 
the  throbs  of  pain,  which  gives  the  attack  a  resem- 
blance to  rheumatism  ;  but  the  severe  pain  is  quite  dif- 
ferent from  a  rheumatic  pain  :  it  occurs  entirely  inde- 
pendent of  any  movement  of  the  limbs ;  the  aching 
between  the  attacks  is  less  than  is  usually  found  in 


228  DISEASES   OF  THE  SPIRAL    CORD. 

rlieTimatism  with  equally  severe  pain  ;  the  part  affected 
is  neither  red  nor  swollen;  the  joints  do  not  so  fre- 
quently snffer  as  other  XDarts  of  the  limbs.  The  unex- 
pected occurrence  of  the  pain,  and  its  severity,  may 
cause  the  sufferer  to  cry  out  and  grasp  the  part  affected. 
The  terms  used  by  patients  are  expressive  ;  they  speak 
of  the  pain  as  resembling  a  "stroke  of  lightning,"  "a 
knife-thrust  into  the  bone,"  "  a  red-hot  iron  suddenly 
buried  in  the  flesh,"  though  the  pain  does  not  always 
have  this  severity.  The  seat  of  the  suffering  varies ; 
the  pain  may  be  in  the  foot,  again  in  the  calf  or  thigh, 
sometimes  in  the  right  leg,  again  in  the  left,  but  gener- 
ally it  does  not  give  a  jDref erence  for  one  side  more  than 
the  other ;  also  in  the  arms  and  head  the  different  at- 
tacks affect  different  localities,  yet,  as  a  rule,  localities 
supplied  by  the  same  plexus  of  nerves. 

So  little  importance  is  given  to  the  above  symptom 
when  first  present,  that  medical  advice  is  rarely  sought 
until  the  attacks  become  more  severe.  Let  the  physi- 
cian be  on  the  watch  to  inquire  into  the  particulars, 
and  ataxia  will  be  oftener  recognized  in  its  earliest 
stage  ;  other  symptoms  will  be  found  confirming  the 
diagnosis. 

During  the  continuance  of  the  pain,  and  for  a  short 
time  after  the  attack  has  ceased,  there  will  be  a  tender- 
ness of  the  part  affected  ;  a  very  light  touch  will  be 
painful,  yet  a  severer  irritation,  as  a  prick  with  a  nee- 
dle, may  be  scarcely  felt. 

The  hypergesthesia  is  of  short  duration  ;  anaesthesia 
is  found  to  be  more  persistent,  and  between  the  attacks 
there  is  diminution  of  sensation  of  touch  as  well  as  of 
pain.  The  ansesthesia  often  affects  the  soles  of  the 
feet ;  it  may  be  found  in  circumscribed  spots  on  the 
limbs  or  body,  on  the  face  or  head  ;  its  distribution  is 
independent  of  the  seat  of  the  pain ;  it  is  generally 
symmetrical.  Localized  anaesthesia  is  as  constant  a 
symptom  as  the  pain,  but  is  less  strikingly  evident  to 
the  patient,  and  may  need  to  be  searched  for  carefully 


LOCOMOTOR  ATAXIA.  229 

by  the  physician.  The  different  forms  of  sensation,  as 
touch,  pain,  temperature,  may  be  affected  separately, 
and  so  each  should  be  tested. 

Delay  in  the  transmission  of  sensation,  so  that  a 
touch  or  prick  is  not  felt  for  several  (three  to  ten  or 
fifteen)  seconds  after  contact,  is  less  frequently  an  early 
symptom,  but  is  often  to  be  noticed  later.  Sometimes 
the  touch  is  first  recognized,  the  pain  is  felt  later,  show- 
ing a  difference  in  the  rate  of  transmission  of  the  two 
varieties  of  sensation. 

A  sense  of  a  girdle  around  the  body  is  often  no- 
ticed. 

The  muscular  sense  is  not  impaired  till  late  in  the 
disease.  The  patient  can  tell  where  his  limbs  are,  even 
when  there  is  m-uch  disturbance  of  motion  ;  but  finally 
he  loses  this  power. 

The  special  senses  may  be  disturbed  early  in  the  dis- 
ease, even  before  any  disturbance  of  general  sensibility. 
Vision  is  affected  much  more  frequently  than  hearing ; 
taste  and  smell  are  very  rarely  lost. 

The  sight  may  be  diminished  by  reason  of  disturb- 
ance of  accommodation,  by  paralysis  of  motor  muscles, 
or  by  limitation  of  the  field  of  vision. 

The  field  of  vision  is  limited  because  of  atrophy  of 
the  optic  nerve.  The  limitation,  often  unilateral  at  first, 
soon  affects  both  eyes  ;  it  begins  on  the  temporal  side, 
and  advances  so  that  the  center  of  the  field  of  vision 
remains  longest  unaffected.  The  ophthalmoscope  will 
show  the  disk  with  the  characteristic  appearance  of 
atrophy.  If  the  change  is  recent,  it  may  be  possible  to 
exclude  a  preceding  neuritis ;  if  old,  the  neuritis  can 
not  be  excluded  with  so  much  certainty.  The  atrophy 
and  consequent  limitation  of  vision  are  permanent. 

The  field  of  vision  for  colors  may  be  limited  when 
perception  of  form  is  still  nearly  or  quite  perfect.  This 
is  a  condition  which  has  not  been  very  carefully  studied 
as  yet. 

The  atrophy  of   the  optic  nerve,  and  consequent 


230  DISEASES  OF  THE  SPINAL   CORD. 

limitation  or  loss  of  vision,  may  be  tli«  only  symptom 
present  for  several  years.  If  witli  this  there  is  absence 
of  patella  tendon  reflex,  the  diagnosis  of  ataxia  may  be 
made  with  a  fair  degree  of  certainty. 

It  may  be  as  well  to  mention  here  the  motor  dis- 
turbances of  the  eyes,  as  they  also  interfere  with  vision. 
The  pupils  may  be  extremely  contracted  ;  they  may  be 
less  contracted  or  even  dilated,  and  not  respond  to  vari- 
ations in  the  amount  of  light,  while  they  will  respond 
to  accommodation.  This  has  been  called  the  "Argyll- 
Robertson  symptom,"  from  its  first  observer.  Buzzard 
suggests  that  slight  changes  in  the  iris  can  be  best  seen 
by  casting  a  strong  light  upon  the  eye  with  the  ophthal- 
moscopic mirror,  and  watching  the  motions  through  a 
convex  lens  of  about  +  8  or  -|-  10  placed  behind  it. 

Presbyopia  is  one  of  the  earlier  ocular  symptoms. 
The  change  is  not  gradual,  as  when  the  consequence  of 
advancing  years,  but,  when  symptomatic  of  tabes,  occurs 
suddenly,  perhaps  in  one  eye  only  ;  after  a  short  time 
this  symptom  may  disappear. 

Diplopia  from  partial  paralysis  of  some  of  the  ex- 
ternal ocular  muscles  is  another  form  of  defective 
vision  ;  there  may  also  be  partial  ptosis  of  one  or  both 
eyelids.  Rarely  nearly  all  the  ocular  muscles  may  be 
affected.  The  paralysis  of  these  muscles  may  pass  away 
and  the  patient  may  almost  forget  its  occurrence  when 
he  applies  for  relief  from  the  later  symptoms  of  ataxia. 

The  hearing  may  suffer  early — one  ear  may  be  af- 
fected or  both  ears  may  be  dull  of  hearing.  In  one  pa- 
tient, where  the  hearing  was  practically  entirely  lost, 
partial  deafness  occurred  suddenly,  then  gradually  in- 
creased in  degree  rather  rapidly. 

Tinnitus  aurium  is  mentioned  as  a  symptom,  but  is 
so  common  under  varying  circumstances  that  it  would 
be  difficult  to  prove  more  than  a  coincidence. 

Visceral  disturbances,  gastric,  nephritic,  laryngeal, 
and  bronchial  crises  are  phenomena  of  disturbed  sensa- 
tion occasionally  met  in  ataxia. 


LOCOMOTOR  ATAXIA.  231 

The  disturbance  called  "gastric  crises"  is  the  most 
important  of  these  visceral  symptoms.  This  may  be 
the  dominant  symptom  for  years,  and  so  absorb  the 
attention  of  both  patient  and  physician  that  other  phe- 
nomena are  overlooked  ;  the  patient  is  thought  to  have 
gastric  ulcer,  nervous  dyspepsia,  chronic  catarrh  of  the 
stomach,  etc.  A  close  questioning  will  bring  to  light 
"rheumatic  pains"  in  the  limbs,  an  examination  may 
show  pupillary  phenomena,  and  tendon  reflex  will  be 
found  absent.    The  diagnosis  can  not  then  be  doubtful. 

These  gastric  crises  are  irregularly  periodical,  recur 
without  certain  cause,  and  without  warning.  The  pa- 
tient is  seized  with  severe  pain  in  the  epigastrium,  as  if 
his  bowels  were  being  tied  up  or  twisted  around  ;  this 
continues  for  a  variable  time,  and  then  vomiting  sets  in, 
at  first  of  ingesta,  then  of  a  glairy  mucus  similar  to  that 
ejected  in  catarrh  or  ulcer  of  the  stomach.  The  amount 
of  vomitus  may  be  very  great,  enormous,  and  the  pa- 
tient is  surprised  at  the  quantity.  With  the  vomiting 
there  is  usually  a  short  period  of  relief,  only  a  slight 
soreness  remaining.  Soon  the  same  scene  is  repeated. 
These  attacks  recur  at  short,  sometimes  long,  intervals, 
for  a  few  days  or  some  weeks,  and  then  cease  for  weeks 
or  months. 

During  the  attack  the  pulse  is  commonly  greatly  in- 
creased in  frequency ;  but  the  temperature  is  not  ele- 
vated. Sometimes  during  the  vomiting  the  severe  shoot- 
ing pains  in  the  limbs  are  felt  in  their  greatest  intensity, 
adding  materially  to  the  patient's  misery. 

Between  the  attacks  the  appetite  and  digestion  are 
good  ;  the  former  may  be  ravenous. 

NepJiritic  crises  have  been  described  by  Raynaud, 
characterized  by  attacks  resembling  renal  colic  with  re- 
traction of  testicles,  anuria  or  ischuria,  vesical  tenes- 
mus, the  attacks  continuing  six  or  eight  days,  recur- 
ring frequently,  separated  by  intervals  of  health.  There 
is  no  blood,  nor  pus,  nor  gravel  found  in  the  urine. 
These  are  much  less  common  than  gastric  crises. 


232  DISEASES  OF  TEE  SPINAL   CORD. 

Laryngeal  crises,  where  there  are  obstinate  and 
causeless  paroxysms  of  coughing,  ending,  perhaps,  in 
spasm  of  the  glottis,  are  even  less  common.  Charcot 
and  Yulpian  have  recorded  cases  of  laryngeal  crises  in 
which  epileptiform  convulsions  occurred  immediately 
after  the  spasm  of  the  glottis. 

The  bronchial  crises,  where  there  is  great  dyspnoea, 
sense  of  constriction  across  the  chest,  as  if  suffocation 
were  impending,  are  also  very  rare. 

The  absence  of  patella  tendon  reflex  (Westphal's 
symptom,  as  it  has  sometimes  been  called)  is  very  con- 
stant in  locomotor  ataxia.  In  order  that  this  phenome- 
non may  be  of  value,  it  is  necessary  that  during  the  ex- 
amination the  knee  should  be  bare,  the  leg  should  hang 
free,  and  there  should  be  no  semi- voluntary  contraction 
of  muscles.  In  doubtful  cases  it  is  well  to  have  the  pa- 
tient shut  his  eyes  and  to  strike  one  knee  or  the  other 
without  giving  him  warning  as  to  where  the  blow  is  to 
fall.  The  absence  of  patella  tendon  reflex  may  be  found 
in  other  diseases,  but  in  locomotor  ataxia  it  is  associ- 
ated with  considerable  voluntary  muscular  power,  and 
when  the  vastus  internus  is  smartly  filliped,  it  is  seen 
to  contract.  Buzzard  and  Erb  both  insist  upon  the 
need  of  these  conditions  as  aids  in  judging  of  the  sig- 
nificance of  the  phenomenon. 

Occasionally  patella  tendon  reflex  is  present  in  an 
undoubted  case  of  locomotor  ataxia,  and  I  have  seen 
cases  where  it  reappeared  after  having  been  absent.  It 
is  absent  in  about  1'5  per  cent  of  healthy  persons. 

This  is  usually  an  early  symptom,  and  by  some  au- 
thors it  is  claimed  that  it  may  be  noticed  before  any 
other  symptom.  It  is  one  of  the  most  constant,  as  will 
be  mentioned  later.  Sometimes,  however,  the  tendon 
reflex  does  not  disappear  till  after  other  symptoms  have 
been  long  present. 

Cutaneous  reflexes  are,  as  a  rule,  retained  in  normal 
intensity,  though  when  there  is  hypersesthesia  the  re- 
flex excited  by  irritating  such  a  spot  may  be  exagger- 


LOCOMOTOR  ATAXIA.  233 

ated,  and,  \rlien  sensation  is  markedly  delayed,  cutane- 
ous reflexes  may  also  be  delayed. 

Motor  disturbances  do  not  belong  to  the  earliest 
symptoms  in  locomotor  ataxia.  The  first  discomfort 
in  this  respect  noticed  by  the  patient  is  a  sense  of  weari- 
ness ;  he  is  more  quickly  tired  than  usual.  This  may 
be  laid  to  various  caused,  and  frequently  is  thought  to 
be  one  result  of  the  rheumatism  which  causes  the  pain. 

At  a  later  period  there  is  a  loss  of  co-ordination  in 
the  use  of  the  muscles.  The  patient  is  aware  that  he 
needs  to  use  his  eyes  in  order  to  walk  reasonably 
straight ;  or,  before  he  is  conscious  of  this,  if  examined, 
he  will  be  found  to  have  lost  the  control  of  his  limbs, 
and  he  can  not  walk  straight  with  his  eyes  shut.*  If  in 
bed,  with  feet  wide  apart,  he  is  told  to  shut  his  eyes, 
raise  one  foot,  and  slowly  carry  it  across  the  bed  and 
bring  it  down  by  the  side  of  its  fellow,  the  foot  is 
moved  irregularly  with  a  jerking  motion  and  is  not 
placed  correctly  in  the  place  mentioned. 

The  inco-ordination  may  affect  the  arms  before  the 
legs,  or  after.  Then  the  patient  has  difficulty  in  feed- 
ing himself  or  in  writing  or  performing  other  acts  re- 
quii'ing  delicate  manipulation.  If,  with  eyes  shut,  he 
is  told  to  touch  the  end  of  his  nose  with  his  forefinger, 
the  finger  will  go  wide  of  the  mark. 

The  gait  of  an  ataxic  is  peculiar  ;  he  walks  with  his 
feet  wide  apart,  straddling ;  they  come  down  heavily 
upon  the  floor,  the  heels  striking  first ;  the  body  sways 
somewhat  from  side  to  side ;  if  the  inco-ordination  is 
great,  support  is  needed,  and  then  the  legs  move  irregu- 
larly. 

Inco-ordination  is  not  as  constant  a  symptom  as 
many  others,  and  is  much  less  important  than  was  for- 
merly supposed. 

With  the  loss  of  complete  control  over  the  limbs, 
and  perhaps  an  inability  to  walk,  there  is  comparatively 
little  loss  of  muscular  strength  ;  while  lying  in  bed,  the 
patient  can  move  freely,  and  resist  passive  flexion  or 


234  DISEASES  OF  THE  SPIFAL   CORD. 

extension  of  the  limbs  with,  great  power.  !N'ot  until 
the  closing  period  of  the  disease  is  there  decided  pa- 
ralysis, except  that  occasionally  a  paralysis,  which  soon 
disappears,  may  follow  a  severe  attack  of  pain. 

Sexual  desire  is  sometimes  exaggerated,  and  hence 
venereal  excess  may  be  one  of  the  symptoms  rather 
than  one  of  the  causes ;  but  it  is  probably  rather  an 
early  symptom  of  the  disease.  Frequent  emissions  are 
also  met.  Sometimes  sexual  desire  is  greatly  increased, 
but  there  is  entire  loss  of  power  to  gratify  the  desire, 
and,  while  suffering  from  it,  there  is  not  the  slightest 
trace  of  erection.  This  impotence  is  not  one  of  the 
earliest  symptoms,  though  it  may  be  noticed  by  the 
patient  before  he  has  given  much  thought  to  the  other 
earlier  symptoms. 

The  bladder  may  be  affected  ;  rarely  there  is  pain 
with  dysuria,  and  frequent  calls  to  empty  the  viscus. 
It  is  more  common  to  have  difficulty  in  voiding  the 
urine  from  partial  paralysis  or  ansesthesia,  and  finally 
the  retention  may  lead  to  cystitis. 

The  bowels  are  usually  unaffected,  except  a  slight 
constipation  ;  but  this  may  give  some  trouble.  Rarely 
there  are  attacks  of  looseness.  When  there  is  great 
angesthesia,  the  fseces  may  pass  without  the  patient's 
knowledge, 

TropliiG  changes  are  not  uncommon ;  among  these 
the  affection  of  the  joints  is  most  striking  and  charac- 
teristic. The  limb  swells  from  effusion  into  the  joint, 
which  may  be  very  great,  and  a  large  part  of  the  limb 
may  be  enlarged ;  there  is  oftentimes  some  redness  and 
slight  pain,  but  these  are  only  moderate.  Within  a 
very  short  time  it  will  be  found  that  the  articular  sur- 
faces forming  the  joint  have  suffered  loss  of  substance, 
and,  when  the  limb  is  moved  in  certain  directions,  crepi- 
tus will  be  felt.  After  a  while  the  serous  effusion  is 
absorbed,  and  the  erosion  of  the  articular  surfaces  con- 
tinues if  the  joint  is  still  used.  The  surface  of  the 
bones  is  roughened,  and  their  chemical  composition 


LOCOMOTOR  ATAXIA.  235 

altered  ;  the  earthy  salts  are  absorbed,  and  a  great  ex- 
cess of  fat  is  deposited. 

The  larger  joints  are  most  commonly  affected — the 
knee  and  hip,  the  elbow  and  shoulder ;  but  the  jaws  and 
smaller  joints  may  be  attacked.  The  chief  characteris- 
tics of  this  change  are  the  sudden  and  rapid  effusion 
into  the  joint,  without  fever,  and  with  but  little  pain, 
if  any  ;  the  early  erosion  of  the  articular  surfaces,  also 
without  pain. 

The  changes  in  the  joints  give  rise  to  dislocations, 
and  the  bones  assume  abnormal  iDositions  ;  the  destruc- 
tion of  ligaments  or  their  elongation  allows  the  limbs 
to  be  hyperextended. 

Occasionally  osseous  growths  form  in  the  vicinity  of 
joints  in  the  soft  parts,  as  if  an  effort  were  made  to 
compensate  for  the  injury  by  the  formation  of  osseous 
splints  or  supports.  Sometimes  the  ends  of  the  bones 
are  not  eroded,  but  undergo  hypertrophy. 

The  change  in  the  composition  of  bones,  which  fa- 
cilitates erosion  of  articular  surfaces,  renders  them  also 
liable  to  fracture  ;  and  this  accident  easily  happens,  not 
only  to  the  long  bones,  but  to  those  of  the  pelvis  as 
well,  sometimes  from  simple  muscular  action.  The 
callus  thrown  out  in  such  cases  is  usually  very  large, 
and  lacks  in  solidity. 

These  osseous  lesions  are  not  among  the  earliest 
symptoms,  but  they  sometimes  are  the  first  to  attract 
notice.  Charcot  places  them  between  the  pains  and 
the  inco-ordination,  though  sometimes  they  appear 
later. 

In  a  few  instances  muscular  atrophy  has  been  seen 
in  cases  of  locomotor  ataxia ;  when  an  autopsy  has  been 
obtained  in  such  cases,  it  has  been  found  that  the  cells 
of  the  anterior  cornua  were  secondarily  affected. 

Less  frequent  than  the  osseous  lesions  we  find  tro- 
phic changes  in  the  skin,  erythema,  herpes,  bullse,  pus- 
tular erujjtions,  ulcerations,  as  mal  perforant.  These 
changes  may  appear  and  disappear  frequently,  and  are 


236  DISEASES  OF  THE  SPIFAL   CORD. 

found  over  the  region  supplied  from  the  plexus,  whence 
arises  the  nerve  in  which  pain  is  felt,  though  the  erup- 
tion may  not  occur  in  the  tract  of  that  nerve.  They  are 
most  frequently  met  during  the  continuance  of  pain. 

Serious  mental  disturbance  is  rare  except  in  those 
cases  associated  with  general  paralysis.  The  symp- 
toms of  ataxia  may  arise  before  those  of  general  pa- 
ralysis appear,  or  the  latter  may  be  primary,  and  the 
spinal  affection  set  in  later. 

Sometimes  the  patient  becomes  irritable  or  melan- 
cholic, but  generally  is  in  good  spirits,  and  very  pa- 
tient. A  very  few  instances  of  suicide  have  occurred 
in  patients  who  dreaded  a  long  and  helpless  illness. 

Among  rarer  symptoms  or  complications  may  be 
mentioned  apoplectic  attacks  with  hemiplegia  (Lecoq) 
and  aphasia,  usually  not  permanent. 

A  form  of  spinal  or  cerebro-spinal  disease,  which  is 
probably  a  sclerosis,  has  been  described  by  Friedreich, 
Carre,  Riitimeyer,  and  others,  under  the  title  of  heredi- 
tary ataxia.  It  attacks  several  members  of  a  family, 
sometimes  appearing  at  the  age  of  four  years,  some- 
times as  late  as  the  eighteenth  year. 

There  is  not  the  lancinating  pain,  the  ataxic  gait 
appears  early,  and  soon  there  is  inco-ordination  of  the 
upper  extremities ;  the  speech  shows  disturbance  of 
co-ordination,  and  there  is  ataxic  nystagmus  ;  tendon 
reflex  is  absent ;  there  is  often  a  slight  diminution  of 
sensibility  ;  muscular  sense  is  not  disturbed  ;  at  length 
there  is  paraplegia  with  contracture  ;  bed-sores  rarely 
form  ;  there  is  no  disturbance  of  the  bladder ;  the  mind 
is  not  affected. 

Rutimeyer  thinks  the  lesion  affects  the  spinal  cord 
primarily ;  the  medulla  oblongata  and  corpora  quadri- 
gemina  secondarily.  It  is  certainly  not  simple  locomo- 
tor ataxia. 

Bernhardt,  Erb,  and  Yoigt  have  given  the  percent- 
age of  cases  in  which  the  different  symptoms  occur  in 
locomotor  ataxia. 


LOCOMOTOR  ATAXIA. 


237 


The  following  table  gives  the  percentages  according 
to  these  three  observers.  The  number  of  cases  of  each 
was  under  sixty ;  the  agreement  between  the  three  is 
noteworthy : 


Tendon  reflex  absent 

Ataxia 

Staggering,  with  eyes  shut 

Staggering,  non-ataxic 

Sense  of  tiredness 

Loss  of  power  in  walking 

Loss  of  strength 

Upper  extremities  affected 

Sensory  disturbance 

Diminished  sense  of  touch 

Diminished  sense  of  place 

Diminished  sense  of  temperature 
Diminished  sense  of  pressure. . . . 
Diminished  sense  of  pain ....... 

Delayed  sensation 

Painful  after  impressions 

Parsesthesia 

Girdle  sensation 

Lancinating  pains 

Diminished  muscular  sense 

Bladder  symptoms 

Constipation 

Impotence 

Gastric  crises 

Immobile  pupil 

Myosis 

Paralysis  of  ocular  muscles 

Diplopia. ...    

Optic  atrophy 


Voigt. 


Per  cent. 

96-5 
93 

93  ' 

95  ' 
59-5 
19 

98  * 
94-5 
35 
45-5 
68 
V2 
41 
89-5 
78 -5 
94-5 
66 
79 
51 
82 
8-5 
68 
45-5 
28 

17-5 


Bernhardt. 


Per  cent. 

95-6 
94-1 


92 


85-9 


81-6 
34-37 


79-5 

76-b7 

43-7 

48'4 
27-2 

39'-6 
10-3 


Erb. 


Per  cent. 
98 
100 
93-5 

97-9 


69 

92'5 
81 

54 

38-7 

'l2-3 


A  resume  of  the  clinical  history  may  group  these 
symptoms  together  more  connectedly. 

The  earliest  symptoms  are  apt  to  be  mistaken  or 
neglected  ;  they  are  a  temporary  diplopia  or  blurring 
of  vision  from  presbyopia,  which  soon  passes ;  occa- 
sional attacks  of  pain  in  different  parts  of  the  body, 
these  sometimes  very  severe,  but  of  momentary  dura- 
tion ;  these  attacks,  thought  to  be  rheumatic,  recur 
■with  increasing  frequency ;  hypersesthesia  during  the 


238  DISEASES  OF  THE  SPINAL   CORD. 

attacks  and  just  after  ;  circumscribed  ansestliesia,  often 
symmetrical ;  more  serious  loss  of  vision  from  atrophy 
of  optic  nerve  ;  pupillary  phenomena,  Argyll-Robertson 
symptom ;  occasionally  deafness  or  tinnitus,  unilat- 
eral or  bilateral ;  weariness  and  rapidly  occurring  tired 
sensation  on  exercising ;  absence  of  patella  tendon  re- 
flex ;  various  trophic  changes  ;  ataxic  gait  and  inco-or- 
dination  with  at  most  only  fugitive  paralysis,  and  rarely 
even  that.  Such  are  the  earlier  symptoms,  and  those 
of  the  fully  developed  disease. 

As  time  elapses,  the  sensory  and  motor  disturbances 
increase  in  gravity  ;  the  ataxic  phenomena  become  more 
and  more  marked,  until  walking  and  even  standing  is 
impossible  ;  sensation  is  finally  entirely  lost ;  the  arms 
as  well  as  the  legs  are  affected ;  the  patient  is  helpless. 
If  to  this  blindness  and  deafness  are  added,  his  condi- 
tion is  pitiable  ;  fortunately,  this  is  rare.  Death  may 
result  from  some  intercurrent  disease,  or  from  exhaus- 
tion. 

The  disease  is  of  long  duration.  The  earlier  stage, 
during  which  the  patient  can  keep  about,  suffering  only 
during  the  attacks  of  pain,  may  continue  for  ten  to 
twenty  years.  There  are  frequent  periods  of  remission, 
or  even  apparent  cure.  The  average  duration  of  typi- 
cal cases  is  eight  or  ten  years. 

Diagnosis. — When  the  history  of  a  case  is  fully 
known,  the  early  occurrence  of  lancinating  pain  in  the 
legs  or  elsewhere,  with  a  sense  of  tiredness,  occurring 
soon  after  exertion  ;  the  pupillary  and  ocular  phenome- 
na ;  the  absence  of  tendon  reflex  ;  the  anaesthesia  ;  and 
the  ataxic  disturbance  of  motion,  occurring  at  a  some- 
what later  period — are  sufficient  for  diagnosis.  At  a 
late  period  of  the  disease,  if  the  history  is  not  known, 
the  diagnosis  might  be  less  clear. 

There  may  be  anaesthesia  and  a  resemblance  to  in- 
co-ordination  arising  from  weakness  in  myelitis  ;  but  in 
this  case  there  will  probably  be  little  or  no  pain,  and 
the  weakness  would  show  itself  when  the  patient  is 


LOCOMOTOR  ATAXIA,  239 

lying  down.  If  the  myelitis  were  at  all  acute,  the  du- 
ration would  probably  have  been  short,  with  some 
febrile  action.  Spinal  meningitis  is  not  likely  to  be  mis- 
taken for  ataxia. 

In  disease  of  the  cerebellum  there  may  be  lack  of 
co-ordination,  with  retention  of  muscular  strength  ;  but 
the  disturbance  of  co-ordination  is  rather  different  from 
that  seen  in  ataxia.  In  walking,  the  patient  has  not 
the  same  gait,  and  there  are  head  symptoms  which  are 
not  found  in  ataxia, 

Cerebro-spinal  sclerosis  generally  differs  from  ataxia 
in  that  there  is  more  muscular  weakness,  tremor  on 
performing  voluntary  acts,  disturbance  of  speech,  little 
or  no  disturbance  of  sensation,  and  ataxic  inco-ordina- 
tion  is  rare.  There  are  cases,  however,  where  the  dis- 
ease has  extended  to  the  posterior  columns,  which  it  is 
almost  or  quite  impossible  to  diagnosticate  from  loco- 
motor ataxia,  especially  if  tremor  is  absent,  as  occa- 
sionally happens. 

Peogistosis.^Iu  advanced  cases  recovery  can  not  be 
expected  ;  there  may  be  pauses  in  the  progress  of  the 
disease,  or  the  patient  may  grow  worse  so  very  slowly 
that  both  he  and  his  friends  are  encouraged  in  the  hope 
of  his  recovery,  but  such  hopes  are  almost  invariably 
delusive.  Seasons  of  apparent  improvement,  in  which 
the  pains  cease  and  the  ataxia  diminishes,  are  not  rare 
in  the  earlier  stages  of  the  disease.  It  is  not  unlikely 
that  reported  cures  are  cases  where  such  improvement 
has  occurred.  If  the  disease  is  not  too  far  advanced, 
its  progress  may  be  checked  by  treatment ;  individual 
symptoms  can  almost  always  be  ameliorated.  The  du- 
ration is  always  long,  extending  over  many  years,  and 
the  knowledge  of  this  fact  is  often  a  source  of  comfort 
to  the  patient  and  his  friends. 

When  the  disease  seems  to  be  of  short  duration,  yet 
to  have  advanced  rapidly — cases  which  seem  to  run  an 
acute  course — the  prognosis  is  less  unfavorable,  though 
in  such  cases  the  diagnosis  is  not  sure.    Lesion  of  pe- 


240  DISEASES  OF  THE  SPINAL   CORD. 

riplieral  nerves  may  give  rise  to  tlie  symptoms  observed 
under  these  circumstances. 

Teeatmeistt. — If  possible,  patients  should  be  re- 
stricted in  regard  to  exercise,  especially  walking,  and 
forbidden  to  over-exert  themselves  so  as  to  cause  a 
sense  of  exhaustion.  They  should  also  avoid  getting 
their  feet  wet,  and  exposure  to  draughts  of  cold  air 
about  the  feet  and  legs.  The  extremities  should  be 
warmly  clothed.  Mental  over- exertion,  excessive  care 
and  worry,  are  only  a  little  less  injurious  than  physical 
exertion.  Much  indulgence  in  coitus  should  be  abso- 
lutely forbidden.  Benefit  is  found  sometimes  from 
confining  the  patient  to  bed  during  several  weeks, 
every  exertion  and  motion  being  forbidden,  the  patient 
not  being  allowed  to  rise  for  any  purpose  whatever. 
This  can  be  endured  by  the  patient  only  when  accom- 
panied with  daily  frictions  and  massage. 

Of  drugs,  nitrate  of  silver,  in  doses  of  one  quarter  to 
one  half  a  grain  three  times  daily,  is  of  great  benefit 
in  many  cases ;  many  times  this  relieves  the  pain  and 
increases  the  feeling  of  strength.  Double  chloride  of 
gold  and  sodium  is  also  recommended.  Ergot  has  been 
much  used  and  commended.  Iodide  of  potassium  is 
sometimes  followed  by  benefit.  The  galvanic  current  is 
well  deserving  of  trial,  and  frequently  seems  to  be  of 
benefit ;  it  should  be  applied  to  the  back,  one  pole 
being  placed  in  the  cervical  region,  either  in  the 
center  of  the  back  or  on  the  side  of  the  neck,  the 
other  pole  being  passed  slowly  over  the  dorsal  and 
lumbar  region.  The  duration  of  the  application  should 
not  exceed  from  five  to  eight  minutes ;  a  compara- 
tively weak  current  should  be  used,  not  so  strong 
as  to  produce  any  discomfort.  The  actual  cautery, 
passed  very  rapidly  over  the  spine,  may  be  of  great 
service. 

In  Europe,  hydrotherapy  is  much  commended.  Cold 
baths  are  not  to  be  recommended ;  cool  baths,  with  a 
temperature  of  from  70°  to  80°,  especially  sponge-baths. 


LOCOMOTOR  ATAXIA.  241 

may  often  be  used  witli  advantage.  Hot  baths  are  to 
be  avoided. 

The  pains  in  the  legs  frequently  require  special 
treatment.  Sometimes  external  applications,  as  lini- 
ments, especially  irritating  liniments,  will  give  relief. 
A  lotion  composed  of  chloroform  and  alcohol,  in  vary- 
ing proportion,  with  a  small  amount  of  tincture  of 
aconite-root,  will  often  give  relief  ;  this  should  be  put 
on  a  piece  of  flannel  wrapped  around  the  limb,  and  cov- 
ered with  a  towel  wet  in  water,  to  prevent  evaporation. 
Sulphide  of  carbon  may  be  used  in  the  same  way. 
Iodide  of  potassium  internally  is  said  to  sometimes 
give  relief.  The  actual  cautery  to  the  back  may  be 
used  to  relieve  the  pain  in  the  legs.  The  galvanic  cur- 
rent may  be  applied  to  the  limb.  If  it  is  possible  to 
relieve  the  pain  without  having  resort  to  morphia,  it  is 
desirable  to  do  so,  especially  in  view  of  the  long  dura- 
tion of  the  disease ;  sometimes,  however,  it  is  neces- 
sary to  use  that  drug,  and  its  effect  is  prompt.  The 
frequent  use  of  morphia  endangers  the  development  of 
the  opium  habit. 

Lately  nerve-stretching  has  been  tried  ;  many  cases 
have  seemed  to  be  temporarily  benefited,  but  it  is  rarely 
that  any  permanent  benefit  has  been  obtained.  The 
lancinating  pains  have  been  more  relieved  than  other 
symptoms  by  this  operation,  which  deserves  further 
trial. 

16 


CHAPTER  XX. 

SCLEEOSIS. 

BoUENEViLLE  et  L.  GuERARD,  De  la  sclerose  en  plaques  disse- 
minees.  Paris,  1869. — ^MoxoN,  W.,  Eight  Cases  of  Insular  Sclero- 
sis, Guy's  Hosp.  Reports,  1875.— Buzzard,  T.,  On  Some  Points 
in  tlie  Diagnosis  of  Spinal  Sclerosis.  Lancet,  July  27, 1878,  p.  Ill, 
— ^WooD,  H.  C,  Multiple  Spinal  Sclerosis.  Med.  Record,  Sept.  21, 
1878,  p,  224.— Althaus,  Julitjs,  Brit.  Med.  Jour.,  May  10,  17, 
24,  31,  1884.— Dickinson,  Med.  Times  and  Gaz.,  Feb.  2,  1878,  p, 
112.— Bastian,  H.  C,    Med.  Times  and  Gaz.,  Oct.  20, 1883,  p.  451, 

Charcot,  Sclerose  des  cordons  laterales.  Gaz.  hebd.,  1865, 
No.  7  ;  Arch,  de  physiol,  1872,  p.  509. — Erb,  Ueber  die  spastische 
Spinalparalyse.  Virch.  Arch.,  Ixx,  1877,  p.  241.— Dreschfeld, 
J.,  A  Contribution  to  tbe  Morbid  Anatomy  of  the  Primary  Lateral 
Sclerosis.  Journal  of  Anat.  and  Physiol.,  July,  1881,  p.  510. — 
Weiss,  N.  ,  Ueber  spastische  Spinalparalyse.  Wien.  med.  Wochen- 
schr.,  Feb.,  1883. — Charcot,  Sclerose  laterale  amyotrophique. 
Gaz.  des  Hop.,  Nov.  20,  1879. — Coxwell,  Amyotrophic  Lateral 
Sclerosis.  Lancet,  Feb.  23,  1884,  p.  343.— Debove  et  Gombault. 
Arch,  de  physiol.,  Sept.,  1879. 

MULTIPLE  SCLEROSIS. 

Multiple  sclerosis  is  tlie  name  given  to  a  chronic  in- 
fiammation  of  tlie  interstitial  tissue  of  tlie  spinal  cord 
and  brain,  occurring  in  patches  of  greater  or  less  size 
scattered  irregularly  throughout  the  white  substance, 
only  rarely  invading  the  gray  substance.  The  proper 
nervous  structures  are  affected  secondarily,  undergoing 
atrophy,  and  finally  disappear. 

Pathological  Aisr atomy. — The  pathological  pro- 
cess is  similar  to  that  found  in  interstitial  inflammation 
in  other  organs.  The  cellular  elements  are  increased  in 
number  and  in  size  ;  the  fibrous  tissue  is  increased  ;  the 


MULTIPLE  SCLEROSIS.  243 

nerve-fibers  suffer  in  their  nutrition,  are  secondarily- 
affected  with  inflammatory  changes,  suffer  atrophy, 
lose  their  medullary  sheaths  ;  the  axis  cylinders  persist 
for  an  indefinite  time,  and  finally  disappear.  There  is 
left  then  a  close  net- work  of  fibers  surrounding  and 
inclosing  nuclei  and  cells  of  the  neuroglia.  Granular 
corpuscles  are  found  in  the  earlier  stages.  The  cord 
acquires  sometimes  a  firm  consistency,  though  it  may 
be  softer  than  normal;  it  has  a  grayish,  translucent 
appearance,  the  white  substance  somewhat  resembling 
thus  the  gray  substance. 

The  walls  of  the  blood-vessels  are  thickened,  and  it 
is  impossible  to  tell  how  soon  this  change  sets  in. 

It  is  only  exceptionally  that  the  nerve-cells  of  the 
gray  substance  are  altered. 

The  spots  of  disease,  varying  greatly  in  size,  may 
be  situated  in  any  portion  of  the  central  nervous  sys- 
tem ;  sometimes  there  are  few  in  the  cord  and  more  in 
the  brain,  or  the  brain  may  be  the  less  affected.  They 
are  found  in  all  parts  of  the  brain,  in  the  crura,  pons, 
and  medulla,  and  are  perhaps  less  frequent  in  the  cere- 
bellum. The  nerves,  especially  the  optic  and  auditory 
nerves,  may  also  be  affected. 

Etiology. — The  cause  of  sclerosis  can  be  definitely 
determined  in  only  a  few  cases.  It  is  a  disease  of  early 
adult  life,  yet  it  is  found  in  childhood,  and  even  in  in- 
fancy, Seeligmuller  reporting  a  case  aged  one  year  and 
nine  months  ;  several  cases  have  been  reported  between 
four  and  ten  years  of  age.  It  is,  however,  most  fre- 
quent between  twenty  and  thirty  years.  Charcot  sets 
forty  as  the  extreme  limit  when  it  appears. 

Heredity  seems  to  have  little  or  no  setiological  influ- 
ence, though  Seeligmuller  reports  four  cases,  all  under 
ten  years,  in  one  family. 

Charcot  and  some  others  following  him  have  stated 
that  the  disease  is  more  common  among  women  than 
men.  This  may  be  so  to  some  extent,  but  statistics 
are  too  meager  to  settle  this  point. 


244  DISEASES  OF  TEE  SPINAL  CORD. 

Accidents  involving  the  spine,  causing  concussion 
or  jar  of  the  cord,  may  be  exciting  causes  of  the  dis- 
ease. Acute  diseases,  typhoid  fever  especially,  may  be 
followed  by  cerebro- spinal  sclerosis.  Protracted  and 
excessive  toil  seems  sometimes  to  be  the  cause ;  also 
mental  disturbances,  as  worry,  anxiety,  or  fright. 

Symptoms.  — After  injuries,  mental  shocks,  or  when 
following  acute  diseases,  cerebro- spinal  sclerosis  may 
develop  rapidly,  so  that  an  early  diagnosis  is  possible. 
Generally,  however,  the  first  symptoms  are  so  insignifi- 
cant that  they  are  not  considered  by  the  patient  to  be 
of  importance,  and  so  are  neglected ;  indeed,  it  is  not 
possible  to  foretell  whether  the  slight  motor  and  sen- 
sory disturbances  which  first  give  warning  of  more  seri- 
ous trouble  will  continue,  or  may  not  prove  mere  tran- 
sitory phenomena. 

The  earlier  symptoms  are  generally  not  continuous ; 
they  are  also  varied  in  character,  sometimes  referable 
to  cerebral  disturbance,  sometimes  to  spinal;  the  pa- 
tient may  be  thought  to  be  hysterical,  or  suffering  sim- 
ply from  neurasthenia. 

Very  frequently  the  first  complaint  is  in  regard  to 
motor  disturbance — there  is  weakness,  and  it  is  difficult 
for  the  patient  to  ascend  or  descend  stairs ;  he  wearies 
sooner  than  usual  in  walking ;  he  can  no  longer  follow 
his  usual  occupation  with  comfort ;  after  a  while  a  tre- 
mor of  the  hand  is  noticed,  the  handwriting  becomes 
less  legible,  and  then  it  is  impossible  to  write  on  account 
of  the  tremor. 

The  disturbances  of  sensation  during  the  earlier 
stages  are  not  constant ;  there  may  be  distress  in  the 
head,  and  sometimes  headache  or  dizziness  ;  severe  pain 
anywhere  is  rare,  though  it  sometitnes  occurs ;  there 
may  be  backache  or  weariness  following  exertion; 
numbness  and  abnormal  tingling  sensations  in  the  limbs 
are  not  uncommon.  Diplopia  and  ambliopia  are  occa- 
sionally noticed.  Nystagmus  is  a  much  more  frequent 
symptom. 


MULTIPLE  SCLEROSIS.  245 

These  earlier  symptoms  may  be  present  for  many 
weeks  or  months  in  such  slight  degree,  or  with  such 
varying  conditions  of  apparent  good  health,  that  no 
notice  is  taken  of  them.  Finally  they  become  so  severe 
as  to  oblige  the  patient  to  acknowledge  that  he  is  ill ; 
it  is  more  frequently  the  tremor  and  weakness  which 
cause  the  most  annoyance.  Often  there  is  so  little  sen- 
sory disturbance,  that  the  patient  does  not  consider 
himself  seriously  sick. 

The  tremor  is  characteristic.  When  at  rest,  the 
limbs  are  quiet  and  motionless  ;  when  a  voluntary 
motion  is  performed,  the  limb  trembles,  at  first  only 
slightly ;  later,  the  tremor  is  so  severe  as  to  interfere 
seriously  with  the  use  of  the  hands.  It  is  seen  most 
clearly  when  the  patient  tries  to  perform  some  act  re- 
quiring a  careful  balancing  of  the  muscular  forces,  as 
the  carrying  a  cup  or  spoon  to  the  mouth,  or  the  use  of 
a  pen.  As  the  disease  advances,  the  trembling  may  in- 
crease until  all  use  of  the  limbs  is  impossible,  or  the 
whole  body  may  be  tossed  about,  or  the  tremor  may 
disappear ;  then  there  is  left  great  weakness,  partial 
paralysis. 

The  legs  are  affected  similarly  to  the  arms,  but  the 
tremor  is  less  easily  recognized  in  them ;  yet,  by  asking 
the  patient  to  execute  movements  with  the  legs  while 
lying  or  seated,  the  tremor  can  be  recognized.  There 
may  be  stiffness  and  weakness  which  interfere  with 
walking,  but  differing  from  the  inco-ordination  found 
in  ataxia.  As  the  disease  advances,  the  instability  and 
weakness  of  the  legs  become  so  great  as  to  oblige  the 
patient  to  give  up  walking. 

The  nystagmus,  which  has  been  mentioned  in  con- 
nection with  ocular  affections,  is  due  to  the  tremor  of 
the  muscles  of  the  eyeball.  The  motion  is  a  lateral 
one ;  it  can  sometimes  be  made  more  prominent  by 
asking  the  patient  to  look  to  one  side  or  at  an  object 
held  near  the  eyes,  so  as  to  require  an  exertion  of  the 
will  to  adjust  the  axes  of  the  eyes  to  distinct  vision — 


246  DISEASES  OF  TEE  SPINAL   COED. 

that  is,  when  the  eyes  are  at  rest  there  is  no  tremor,  but 
a  voluntary  effort  causes  it. 

Allied  to  the  other  motor  disturbances  is  a  peculiar 
manner  of  speaking :  at  first  there  is  merely  a  slight 
hesitation,  a  drawling  utterance ;  then  there  is  more 
delay  in  pronouncing  the  individual  syllables,  and  the 
sentences  are,  as  it  were,  scanned.  Some  disturbance 
of  speech  is  very  common. 

Reflex  motions  are  not  lost,  may  be  somewhat  ex- 
aggerated, especially  the  patella-tendon  reflex,  except 
toward  the  close  of  the  disease,  or  in  the  rare  cases 
where  the  posterior  columns  are  much  affected.  Ankle 
clonus  may  be  present  when  the  lateral  columns  are 
considerably  diseased ;  it  may  appear,  and  after  a  while 
disappear,  according  to  changes  in  the  cord  during  the 
IDrogress  of  the  disease. 

The  electrical  reaction  of  the  muscles  is  not  altered 
unless,  in  rare  instances,  the  disease  invades  the  ante- 
rior cornua,  and  then  there  is  muscular  atrophy. 

In  the  later  stages,  sensation  may  be  more  affected, 
and  spots  of  anaesthesia  may  be  found  scattered  over 
the  limbs  or  body.  Pain  is  rare  even  in  the  later  stages. 
Disagreeable  sensations  of  tingling,  formication,  a  sen- 
sation as  if  the  limbs  were  asleep,  are  not  uncommon. 
A  sinking  or  faint  feeling  may  give  much  distress. 

Sometimes  the  cerebral  symptoms  are  very  promi- 
nent; headache,  dizziness  or  vertigo,  change  of  dispo- 
sition, mental  heaviness,  are  among  the  more  frequent 
cerebral  symptoms. 

Pseudo-apoplectic  attacks  may  occur ;  the  patient 
suddenly  becomes  unconscious,  is  hemiplegic,  and  may 
have  convulsions  ;  the  symptoms  closely  resemble  those 
of  an  ordinary  attack  of  cerebral  haemorrhage.  The 
attack  may  end  fatally,  or  gradually  consciousness  is 
regained,  the  motor  power  returns,  and  the  patient  re- 
covers, yet  is  usually  not  quite  so  well  as  before  the 
attack.  The  course  of  the  temperature  is  a  valuable 
aid  in  diagnosis  in  these  attacks.   According  to  Charcot, 


MULTIPLE  SCLEROSIS.  247 

the  temperature  rises  with  the  commencement  of  the 
attack,  and  may  reach  104°  within  twenty-four  hours  ; 
unless  death  occurs,  the  temperature  falls  to  normal  by 
the  second  or  third  day.  The  pulse  is  also  rapid  at  the 
beginning  of  the  attack.  Several  of  these  apoplecti- 
form attacks  may  occur  at  intervals  during  the  course 
of  the  disease. 

When  the  interstitial  changes  affect  the  posterior  col- 
umns, we  may  have  symptoms  of  locomotor  ataxia  com- 
plicating and  masking  those  of  the  original  disease. 
When  the  lateral  columns  are  chiefly  affected,  symp.- 
toms  corresponding  with  the  location  of  the  disease 
will  be  noticed. 

Besides  cerebro- spinal  multiple  sclerosis,  some  au- 
thors recognize  a  cerebral  form  and  a  spinal  form  of  the 
disease.  While  it  is  true  that  the  brain  or  spinal  cord 
may  be  chiefly  affected,  it  is  very  rare  that  either  is 
exclusively  the  seat  of  the  disease.  Occasionally  the 
spinal  symptoms  predominate,  all  mental  phenomena, 
even  trembling,  being  absent.  Such  a  case  may  resem- 
ble simple  chronic  myelitis,  except  that  the  symptoms 
are  more  general  and  advance  more  irregularly  than  in 
that  disease.  It  is  very  doubtful  whether  cerebral 
sclerosis  has  ever  been  seen  without  lesion  of  the  spinal 
cord. 

DiAG]srosis. — Multipile  sclerosis  was  formerly  con- 
founded with  paralysis  agitans  on  account  of  the 
tremor.  If  the  nature  of  this  tremor  is  observed,  it  is 
scarcely  possible  to  make  such  a  mistake  ;  in  sclerosis 
the  tremor  ceases  when  the  limbs  are  at  rest,  or  is  very 
much  less  marked  in  the  few  cases  where  it  is  so  severe 
as  to  be  nearly  constant.  In  paralysis  agitans  the 
tremor  is  at  least  as  well  marked  during  repose,  and 
usually  it  is  much  diminished  during  voluntary  exer- 
tion. 

Ordinary  cases  of  chorea  and  multiple  sclerosis  are 
not  likely  to  be  mistaken,  except  where  the  tremor  of 
sclerosis  is  extremely  severe  and  almost  continuous. 


248  DISEASES  OF  TEE  SPINAL   CORD. 

There  is  mncli  similarity  between  tlie  motions  in  sucli  a 
case  and  those  found  in  severe  cases  of  chorea.  A  care- 
ful study  of  the  history  and  course  of  the  disease 
would  probably  prevent  a  mistake. 

Cerebral  pachymeningitis  may  also  resemble  multi- 
ple sclerosis,  but  a  careful  study  of  the  history  of  the 
case  and  examination  of  the  symptoms  will  guard 
against  error. 

When  the  sclerosis  affects  the  posterior  columns  of 
the  spinal  cord,  the  symptoms  may  correspond  in  many 
respects  with  those  found  in  locomotor  ataxia.  If  the 
tremor  is  slight,  or  has  not  shown  itself,  and  the  tendon 
reflex  is  lost,  it  may  not  be  possible  to  make  a  correct 
diagnosis.  When  the  characteristic  tremor  is  present, 
and  the  tendon  reflex  is  retained,  there  should  not  be 
any  mistake  made. 

It  may  not  always  be  easy  to  decide  the  diagnosis 
between  sclerosis  and  general  paralysis,  especially  if 
the  mental  symptoms  are  slight  or  entirely  absent  in 
the  latter.  In  general  paralysis  there  is  tremor  of  the 
facial  muscles  and  tongue  during  voluntary  motion 
rather  than  of  the  muscles  of  the  extremity  ;  the  pupils 
may  be  unequal ;  the  disturbance  of  speech  is  different, 
the  person  talks  with  an  indistinctness  of  utterance 
and  a  hesitation,  repeating  his  words  or  sentences, 
sometimes  pausing  for  a  few  seconds  or  a  minute,  then 
finishing  his  sentence.  In  sclerosis  the  patient  is  aware 
that  his  health  is  defective  ;  in  general  paralysis  he 
seems  to  consider  himself  well,  and  does  not  recognize 
symptoms  which  are  evident  to  others.  If  delusions  of 
grandeur  or  other  mental  disturbances  characteristic 
of  general  paralysis  show  themselves,  the  diagnosis,  of 
course,  is  easy. 

PEOGisrosis. — When  once  multiple  sclerosis  has  been 
certainly  recognized,  we  must  consider  that  the  patient's 
fate  is  sealed,  that  he  will  not  recover  health,  that  the 
disease  will  probably  steadily  progress  to  a  fatal  ter- 
mination unless  life  is  shortened  by  some  intercurrent 


MULTIPLE  SCLEROSIS.  249 

affection.  The  progress  of  the  disease  may,  however, 
be  interrupted  by  remissions  of  longer  or  shorter  dura- 
tion ;  during  these  the  severity  of  the  symptoms  may 
diminish,  and  there  may  seem  to  be  a  flattering  pros- 
j)ect  of  recovery,  but  the  symptoms  are  sure  to  return. 

It  is  not  possible  to  fix  the  duration  of  the  disease 
with  any  degree  of  certainty  ;  from  the  time  the  nature 
of  the  affection  is  recognized  to  the  fatal  termination 
may  be  only  twenty  or  thirty  months,  but  is  usually 
much  longer,  and,  if  the  disease  is  confined  chiefly  to 
the  spinal  cord,  its  duration  may  extend  to  fifteen  or 
twenty  years. 

Teeatment. — The  general  testimony  of  observers  is 
that  treatment  is  frequently  of  no  avail.  The  remedies 
which  have  proved  of  temporary  value  are,  nitrate  of 
silver  in  doses  of  from  i  to  |-  grain  three  times  a  day ; 
double  chloride  of  gold  and  sodium,  -^  grain ;  ergot, 
iodide  of  potassium,  and  arsenic  either  by  mouth  or 
subcutaneously.  Bathing  has  been  recommended  ;  the 
baths  should  be  neither  too  cold  nor  too  hot,  but  cool 
rather  than  warm.  Greater  advantage  may  be  expected 
from  a  persistent  use  of  electricity ;  the  applications 
should  be  made  daily  or  every  other  day  with  the  gal- 
vanic current,  not  too  strong,  to  the  back,  one  pole  above, 
the  other  below,  over  the  spine ;  the  direction  of  the 
current  is  a  matter  of  indifference — it  may  be  varied  at 
different  sittings.  A  much  weaker  current  may  be 
passed  transversely  through  the  head,  the  poles  being 
placed  behind  the  ears ;  great  care  must  be  taken  not 
to  use  too  strong  a  current.  To  obtain  good  results 
from  electricity,  it  must  be  continued  through  many 
months. 

Patients  should  not  be  allowed  to  fatigue  themselves, 
either  by  attending  to  the  ordinary  occupations  of  life, 
or  by  taking  exercise  under  the  impression  that  it  will 
strengthen  them ;  over-fatigue  of  mind  should  also  be 
avoided  ;  alcoholic  drinks  had  better  be  forbidden,  and 
tea  or  coffee  used  only  in  moderation. 


250  DISEASES  Oi   THE  SPINAL   CORD. 

SCLEROSIS  OF  THE  LATERAL  COLUMNS. 

This  affection  has  also  been  called  spastic  spinal 
paralysis  and  spasmodic  tabes  dorsalis,  and,  though  pre- 
vionsly  described  by  Tiirck,  was  first  recognized  as  a 
distinct  form  of  sclerosis  by  Charcot,  and  later  by  Erb. 
Though  for  some  years  there  was  doubt  whether  scle- 
rosis of  the  lateral  columns  can  properly  be  considered 
a  distinct  disease,  the  opinion  seems  to  be  gaining 
ground  that  it  is  distinct  from  other  lesions  of  the 
cord. 

Pathological  Anatomy. — The  pathological  changes 
are  such  as  are  found  in  locomotor  ataxia,  and  are 
generally  confined  to  the  lateral  pyramidal  tract — that 
portion  of  the  lateral  columns  affected  by  secondary 
descending  degeneration.  The  pathological  change 
may  extend  somewhat  beyond  this  region.  A  variety 
of  lateral  sclerosis,  called  by  Charcot  amyotrophic,  is 
characterized  by  destruction  of  the  nerve-cells  in  the 
anterior  cornua,  in  addition  to  the  changes  in  the  lat- 
eral columns. 

The  causes  are  obscure,  and  no  satisfactory  obser- 
vations have  been  made  on  that  point. 

Symptoms. — The  motor  symptoms  are  most  promi- 
nent, and  may  commence  in  the  upper  or  lower  ex- 
tremities ;  rather  more  frequently,  perhaps,  in  the  latter. 
First  is  noticed  a  slight  weakness  and  tendency  to  be- 
come easily  fatigued.  The  weakness  gradually  in- 
creases until  the  patient  has  great  difficulty  in  getting 
about,  or  is  confined  to  the  bed.  This  symptom  may 
first  appear  in  one  limb  only ;  but  after  a  while  the 
other  limb  is  also  affected,  and  before  death  all  four 
extremities  are  usually  implicated.  Ataxic  symptoms 
are  very  seldom  seen. 

Besides  the  above  paralytic  phenomena,  a  class  of 
symptoms  are  developed  which  are  peculiar  to  lesions 
of  the  pyramidal  tracts.  These  may  appear  even  in 
the  early  stages  of  the  disease,  when  the  weakness  is 


SCLEROSIS  OF  THE  LATERAL   COLUMNS.         251 

as  yet  very  slight ;  they  consist  in  spasmodic  jerkings 
and  tremors,  with  other  signs  of  irritation. 

The  tendon  reflex  is  greatly  exaggerated ;  a  very 
slight  tap  just  below  the  knee  causes  the  leg  to  jerk 
forward  with  considerable  force ;  other  tendons  also 
show  an  increase  of  reflex  irritability,  as  in  the  arms 
just  above  the  olecranon  at  the  elbow,  over  the  tendon 
of  the  triceps,  or  at  the  wrist,  and  sometimes  over  the 
tendons  of  the  muscles  of  the  shoulder  and  neck.  An- 
kle clonus  is  generally  very  strong. 

Owing  to  this  increase  of  tendon  reflex,  the  patient' s 
gait  is  peculiar,  called  by  Erb  the  spastic  gait,  and  thus 
described  by  him:  "The  legs  are  somewhat  dragged, 
the  feet  seem  to  cleave  to  the  ground,  the  tips  of  the 
feet  find  an  obstacle  in  every  inequality  of  the  ground  ; 
every  step  is  accompanied  by  a  peculiar  hopping  eleva- 
tion of  the  whole  body,  dependent  on  a  reflex  contrac- 
tion of  the  calf ;  the  patient  immediately  gets  upon  his 
toes  and  slips  forward  on  them,  showing  a  tendency 
to  fall  forward.  The  legs  are  close  together,  held 
stiffly,  the  knees  somewhat  depressed  forward.  There 
is  no  throwing  about  of  the  feet.  This  gait  depends  on 
muscular  tension  and  reflex  contractions  in  the  various 
groups  of  muscles,  which  are  set  in  activity  during  the 
process  of  walking." 

The  increase  of  reflex  irritability  is  shown  by  spon- 
taneous jerking  and  twitching  of  the  limbs  occurring 
when  the  patient  is  lying  down,  but  in  extreme  cases 
occurring  also  when  he  is  sitting.  The  extensor  mus- 
cles are  most  frequently  affected  ;  sometimes,  however, 
the  flexors  draw  the  knees  and  legs  spasmodically ;  the 
spasm  consists  simply  of  a  strong  tremor  of  the  limbs, 
which  is  often  excited  by  the  act  of  stretching.  A 
spasmodic  stiffness  of  the  limbs,  at  first  intermittent, 
interferes  with  motion ;  when  this  stiffness  becomes 
continuous,  there  is  permanent  contracture  of  the 
limbs,  the  legs  and  feet  being  extended,  the  toes  are 
sometimes  flexed ;  the  adductor  muscles  keep  the  legs 


252  DISEASES  OF  THE  SPINAL  CORD. 

closely  approximated  to  each  other.  The  arms  are 
much  less  frequently  affected  with  contracture. 

Erb  found  the  skin  reflexes  generally  normal  in 
about  two  thirds  of  his  cases,  increased  in  hardly 
one  third.  He  found  the  faradic  and  galvanic  excit- 
ability of  the  motor  nerves  slightly  lowered,  never 
increased. 

The  functions  of  the  bladder  and  rectum,  and  the 
sexual  function,  are  not  interfered  with. 

There  are  no  brain  nor  bulbar  symptoms.  Sensa- 
tion is  not  disturbed  when  only  the  lateral  columns  are 
diseased. 

AMYOTROPHIC  LATERAL  SCLEROSIS. 

Charcot  first  described  a  form  of  disease  in  which 
sclerosis  of  the  lateral  columns  is  associated  with  atro- 
phy and  destruction  of  the  cells  of  the  anterior  cornua. 
The  pathological  changes  are  the  same  as  those  in  lat- 
eral sclerosis,  with  the  addition  of  destruction  of  nerve- 
cells  of  the,  anterior  cornua,  those  in  the  upper  part  of 
the  cervical  region  being  most  affected ;  one  group  of 
cells  is  not  more  likely  to  be  diseased  than  another ; 
both  sides  are  usually  affected.  The  hypoglossal  nu- 
cleus, and  sometimes  the  other  nerve-centers  of  the  me- 
dulla oblongata,  may  be  affected  as  well  as  the  cells  in 
the  cervical  region  of  the  cord. 

The  nerve-roots  and  trunks,  which  take  their  origin 
from  the  diseased  cornua,  suffer  secondary  atrophy, 
and  the  muscles  supplied  by  them  undergo  the  usual 
atrophic  changes. 

The  first  symptom  is  a  weakness  of  the  hands,  fol- 
lowed soon  by  wasting  and  spasmodic  rigidity  ;  fibril- 
lary contractions  are  generally  to  be  seen  in  the  affected 
muscles.  Finally,  the  symptoms  of  bulbar  paralysis 
(labio-glosso-laryngeal  paralysis)  show  themselves  ;  the 
tongue  and  lips  are  paralyzed,  swallowing  is  difficult  or 
impossible,  and  speech  is  very  much  interfered  with. 
The  legs  rarely  show  marked  signs  of  wasting ;   the 


AMYOTROPHIC  LATERAL  SCLEROSIS.  253 

symptomsj  as  already  described  as  due  to  lateral  scle- 
rosis, are  developed  in  the  legs. 

The  electrical  contractility  of  the  muscles  suffers 
in  so  far  as  there  is  atrophy.  Sensation  is  but  little 
disturbed,  though  there  is  sometimes  a  painful  hyper- 
sesthesia  of  the  muscles  affected.  Sometimes  the  con- 
tractures disappear  before  death. 

The  prognosis  is  decidedly  unfavorable,  and  the 
course  of  the  disease  much  more  rapid  than  that  of 
simple  lateral  sclerosis,  the  usual  duration  being  only 
two  or  three  years. 

Peognosis  and  Diagnosis. — The  progress  of  the 
disease  is  very  slow,  and,  interrupted  by  periods  of  re- 
mission, it  may  extend  through  many  years. 

Recovery  is  more  frequent  in  cases  of  lateral  sclero- 
sis than  in  many  other  forms  of  chronic  disease  of  the 
spinal  cord.  The  disease  itself  rarely  causes  death,  the 
fatal  termination  usually  occurring  in  consequence  of 
some  complication. 

There  is  no  other  disease  in  which  such  a  complex  of 
symptoms  is  found  as  described  above  ;  the  reflex  and 
spasmodic  phenomena  are  peculiar,  and,  so  far  as 
known,  occur  only  when  the  lateral  pyramidal  tracts 
are  affected.  When  these  tracts  are  subject  to  second- 
ary degeneration,  the  result  of  cerebral  disease  or  dis- 
ease of  the  mesencephalon,  similar  reflex  phenomena 
are  observed ;  but  then  the  history  of  the  origin  and 
progress  of  the  disease  will  render  a  diagnosis  easy, 
and  even  without  these  the  hemiplegic  character  of  the 
symptoms  would  indicate  their  cerebral  origin. 

In  multiple  sclerosis  the  lateral  columns  may  be 
chiefly  affected,  in  which  case  the  symptoms  peculiar 
to  such  lesion  will  predominate,  and,  if  the  disease  ex- 
tends but  little  beyond  those  columns,  an  error  of  diag- 
nosis is  inevitable.  Generally,  however,  there  will  be 
other  symptoms  pointing  in  the  right  direction.  The 
physician's  skill  will  be  tested  in  unraveling  the  com- 
plication of  symptoms  so  as  to  recognize  those  depend- 


254  DISEASES  OF  TEE  SPINAL   CORD. 

ing  upon  lateral  sclerosis  and  those  depending  npon 
sclerosis  of  other  parts. 

Teeatment. — Comparatively  little  may  be  said  in 
regard  to  treatment ;  nitrate  of  silver  is  recommended 
by  some.  Erb  mentions  the  galvanic  current  as  afford- 
ing the  best  results  ;  he  also  favors  a  "reasonably  con- 
ducted water  treatment  " ;  indeed,  the  treatment  is  very 
similar  to  that  in  other  cases  of  chronic  myelitis. 


CHAPTER  XXI. 

PSEUDO-HYPEETEOPHIC   PAEALTSIS. 

DUCHENNE,  Gr.  B.,  De  relectrisation  localisee,  3"'  edit.,  1872. 
— Ord,  W.  M.,  Notes  of  a  Case  of  Duchenne's  Pseudo-hypertrophic 
Muscular  Paralysis.  Med.  Chir.  Trans.,  2d  Series,  vols,  xxxix, 
xlii.— PoORE,  C.  T.  New  York  Med.  Jour.,  1876.— Moore,  M. 
Lancet,  June  19,  1880.— Gerhard,  G.  S.  Phila.  Med.  Times, 
Oct.  16,  1875.— GOWERS,  Pseudo-hypertrophic  Paralysis.  Lon- 
don, 1879. 

^TioLOOY. — This  disease  is  almost  confined  to  males, 
very  few  cases  having  been  seen  among  females.  It  is 
not  uncommon  to  find  several  cases  in  the  same  family, 
the  boys  being  affected,  and  the  girls  as  a  rule  escai^ing. 
When  several  branches  of  a  family  are  affected,  the  dis- 
ease is  almost  invariably  found  among  the  mother's 
relatives,  not  the  father's. 

The  subjects  of  pseudo-muscular  hypertrophy  are 
children  ;  very  few  adults  are  attacked  ;  it  usually  be- 
gins before  six  years,  and  sometimes  before  the  child 
learns  to  walk.  Gowers  finds  that  it  begins  later  in 
girls  than  in  boys. 

The  conditions  or  circumstances  which  cause  the 
disease  to  appear  are  unknown. 

Symptoms. — The  earliest  noticeable  symptom  is 
diminution  of  motor  power  :  the  child  either  learns  to 
walk  late,  or  loses  its  steadiness  and  acquires  peculiari- 
ties of  gait  and  posture.  Notwithstanding  this  weak- 
ness, the  muscles  seem  to  be  of  good  size,  especially 
those  of  the  calves,  and  the  parents  think  it  is  strange 
that,  with  such  large,  plump  legs,  their  children  find  so 


256  DISEASES  OF  TEE  SPINAL  CORD. 

mucli  trouble  in  getting  about.  This  apparent  hyper- 
trophy may  be  noticed  in  other  muscles,  as  those  of 
the  thigh,  the  glutsei,  more  rarely  those  of  the  upper 
extremity.  Duchenne  gives  a  representation  of  a  pa- 
tient who  had  enlargement,  apparently,  of  all  the  mus- 
cles except  the  pectorals,  which  were  atrophied. 

Slowly  the  weakness  extends  and  increases  ;  the  en- 
largement of  muscles  does  not  extend,  but  the  loss  of 
power  is  usually  attended  with  atrophy,  so  that  the  pa- 
tient finally  appears  reduced  almost  to  a  skeleton  with 
enormously  large  legs. 

The  loss  of  power  in  various  muscles  leads  to  pecul- 
iarities of  posture  and  gait  which  are  characteristic. 
The  patient,  in  standing,  throws  his  abdomen  forward, 
his  shoulders  backward,  and  bends  his  head  slightly 
forward  so  as  to  keep  his  balance.  Duchenne  thinks 
this  posture  is  caused  by  weakness  of  the  muscles  of 
the  back.  Gowers  ascribes  it  to  weakness  of  the  exten- 
sors of  the  hip,  which  causes  the  pelvis  to  incline  for- 
ward more  than  normal.  When  this  lordosis  is  marked, 
if  the  patient  stands,  a  plumb-line  falling  from  the 
shoulders  passes  more  or  less  in  rear  of  the  sacrum.  In 
standing,  the  patient  keeps  his  feet  widely  separated, 
and  walks  with  a  waddling  or  rolling  gait,  which  de- 
pends upon  the  weakness  of  the  glutsei. 

When  the  weakness  has  advanced  only  a  little,  the 
patients  need  to  help  themselves  with  their  arms  in  ris- 
ing from  a  chair,  and,  if  the  loss  of  power  is  consider- 
able, the  patient  must  help  himself  more,  and,  so  to 
speak,  climbs  up  his  own  legs.  Gowers  describes  the 
different  ways  in  which  patients  assist  themselves : 
Some  put  their  hands  on  their  knees,  then  on  the 
thighs,  grasping  them,  and  the  hands  are  moved  alter- 
nately higher  and  higher  until  they  are  upright ;  oth- 
ers, to  rise  from  the  floor,  take  a  position  on  hands  and 
knees,  then  on  hands  and  feet,  or  rather  toes,  with  the 
feet  wide  apart,  then,  moving  the  hands  backward  on 
the  ground  till  the  legs  are  nearly  perpendicular,  they 


PSEUDO-ETPERTROPEIG  PARALYSIS.  257 

put  one  liand  on  one  knee,  and  with  a  sliglit  spring  rise 
iilDrigTit. 

Fibrillary  twitchings  are  often  seen  in  muscles  un- 
dergoing atrophy,  as  in  progressive  muscular  atrophy. 

Reflex  functions,  cutaneous  and  tendinous,  suffer, 
apparently,  according  to  the  amount  of  disease  in  the 
muscles. 

Electrical  reactions  are  diminished  in  proportion  to 
the  muscular  atrophy  and  the  amount  of  fat  deposited, 
a  large  increase  of  fat  making  it  necessary  to  use  a 
stronger  current  to  obtain  equal  reaction. 

Sensibility  is  not  disturbed,  and  it  is  very  rare  that 
there  is  pain. 

Mental  powers  are  only  exceptionally  blunted.  In 
a  few  cases  epileptic  fits  have  been  recorded ;  but,  as 
Gowers  says,  they  are  probably  the  result  of  an  associ- 
ated, not  of  a  related,  cerebral  disease. 

The  progress  of  the  disease  is  slow  ;  gradually  one 
muscle  after  another  is  affected,  sometimes  one  side  be- 
ing attacked  a  little  before  the  other,  but  usually  both 
nearly  together.  There  are  periods  of  quiescence,  but 
the  tendency  is  steadily  onward.  When  the  disease 
commences  early,  life  is  not  prolonged  many  years ; 
when  later,  the  patients  may  live  to  adult  years.  Usu- 
ally death  occurs  between  ten  and  twenty-five.  Death 
is  usually  caused  by  some  intercurrent  disease,  often  of 
the  respiratory  organs. 

Pathological  Akatomy. — The  hypertrophied  mus- 
cles are  found  at  the  autopsy  to  be  largely  composed  of 
fat ;  the  muscular  fibers  are  diminished  in  size  and 
widely  separated  by  masses  of  connective  tissue  filled 
with  fat.  Statements  of  observers  do  not  agree  as  to 
fatty  degeneration  of  the  muscular  fibers  ;  probably  it 
sometimes  occurs ;  they  more  frequently  suffer  simple 
atrophy.  Finally,  the  muscular  tissue  disappears  and 
gives  place  to  fibrous  tissue. 

Changes  in  the  spinal  cord  are  not  constant.  Many 
times  none  have  been  found,  sometimes  the  cells  of  the 


258  DISEASES  OF  THE  SPINAL   CORD. 

anterior  cornua  are  more  or  less  diseased,  and  some- 
times the  wMte  substance  near  the  gray  is  diseased. 
Gowers  concludes  that  pseudo-hypertrophic  paralysis 
of  early  life  is  not  a  disease  of  the  spinal  cord. 

The  only  constant  change  found,  in  all  cases,  so  far, 
has  been  the  muscular  degeneration.  I  am  not  pre- 
pared to  accept  Friedreich's  views  as  to  the  nature  of 
the  affection.  I  can  not  form  any  satisfactory  theory, 
and  must  leave  that  for  the  developments  which  may 
be  learned  in  the  future. 

DiAGisrosis. — There  is  no  danger  of  mistaking  the 
fully  developed  disease  if  care  is  taken  in  examination. 
If  the  legs  or  thighs  are  not  much  hypertrophied,  there 
may  be  some  doubt  about  the  nature  of  the  disease,  and 
progressive  muscular  atrophy  may  be  thought  to  be 
present.  In  the  earliest  stage  a  portion  of  muscle  may 
be  removed  by  a  "harpoon,"  and  examined  under  the 
microscope  in  order  to  settle  the  diagnosis. 

PEOGisrosis. — The  most  that  can  be  hoped  is  that  the 
disease  vdll  cease  advancing  for  a  while.  What  has 
been  said  in  regard  to  its  course  and  progress  will  aid 
to  an  intelligent  prognosis.  If  in  any  case,  however, 
friends  desire  to  know  how  long  a  child  thus  afflicted 
will  live,  we  need  to  be  cautious  about  giving  a  definite 
answer.    We  do  not  know. 

Teeatment. — The  plan  recommended  for  progres- 
sive muscular  atrophy  is  that  which  is  most  rational. 
Gowers  has  obtained  slight  benefit  from  arsenic  and 
from  phosphorus. 


DISEASES  OF  THE  PERIPHERAL 

AND 

SYMPATHETIC  NERVES. 


CHAPTEE  XXII. 

NEUEITIS. 

Mitchell,  S.  Weir,  Injuries  of  Nerves  and  their  Consequen- 
ces. Philadelphia,  1872.— Niedick,  W.,  Ueher  Neuritis  Migrans 
uud  ihre  Folgezustande.  Arch.  f.  exper.  Pathol.^  vii,  1876,  p. 
205. — Mills,  C.  K.,  Traumatic  Neuritis  involving  the  Brachial 
Plexus.  Philadelphia  Med.  Times,  1877,  p.  564. — Treub,  Hec- 
tor, Ueber  Reflexparalyse  iind  Neuritis  Migrans.  Arch.  f.  exper. 
Pathol..,  X,  1879,  p.  398. — Gombatjlt,  Contribution  a  I'etude  anato- 
mique  de  la  nevrite  parenchymateuse  subaigue  et  chronique. 
Arch,  de  nevrolog. ,  i,  1880,  pp.  11,  127. 

Multiple  Neuritis.— EiCHHORST,  H.  Virch.  Arch.,  69,  1877,  p. 
265.— Leyden.  Charite  Ann.,  v,  1880,  p.  206.— Stewart.  Edin- 
burgh Med.  Jour.,  1881,  vol.  xxvi,  p.  865. — Caspari.  Zeitschr.f.  M. 
Med.,  1882,  p.  537. — Pierson.  Volkmann''s  Sammlung,  No.  224, 
1883.— Strumpell.  Arch.  f.  Psych.,  xiv,  1888,  p.  339.— Muller. 
Ibid.,  p.  669.— Vierordt.  Ibid.,  p.  678.— Webber,  S.  Gt.  Archives 
of  Med.,  xii,  Aug.,  1884.— Scheube,  B.,  Die  Japanische  Eak-ke 
(Beri-beri).    Deut.  Arch.  f.  Jcl.  Med.,  31,  1882,  p.  141  et  seq. 

SIMPLE  NEURITIS. 

Pathological  Anatomy. — The  nerve-fibers,  or  the 
slieatli  of  the  nerve,  may  be  the  seat  of  inflammation, 
which  may  be  acute  or  chronic.  When  the  nerve-fibers 
are  affected,  the  nuclei  in  the  neurilemma  are  multi- 
plied, the  medullary  substance  divides  and  undergoes 
a  granular  or  fatty  degeneration,  the  axis  cylinder  may 
be  hypertrophied,  but  finally  is  destroyed,  and  there 
remains  only  a  fibrous  band  in  place  of  the  nerve.  When 
the  sheath  of  the  nerve,  the  perineurium,  is  chiefly  af- 
fected, it  becomes  thickened  by  formation  of  new  tis- 
sue and  the  infiltration  of  serum ;  the  nerve-fibers  are 
compressed,  and  undergo  degeneration  secondarily. 


262       DISEASES  OF  THE  PERIPHERAL  NERVES 

In  acute  neuritis  the  nerve  is  rather  more  congested, 
the  nerve-fibers  are  the  more  frequently  most  affected, 
and  pus  is  more  likely  to  form ;  sometimes  haemor- 
rhages occur  into  the  sheaths  of  the  nerve,  leaving 
pigmentation  after  the  blood  has  been  absorbed. 

Chronic  neuritis  may  follow  as  the  result  of  acute, 
or  may  occur  spontaneously  ;  the  sheath  is  more  likely 
to  be  the  chief  seat  of  the  disease,  and  the  nerve-trunk 
is  thereby  much  thickened.  The  nerve-fibers  degener- 
ate and  undergo  atrophy. 

The  nerve  beyond  the  seat  of  inflammation  under- 
goes the  secondary  Wallerian  changes  when  the  fibers 
are  entirely  severed. 

Trophic  changes  in  the  limbs  may  follow  as  results 
of  the  neuritis. 

Etiology. — Injuries  are  the  most  common  cause  of 
neuritis.  All  kinds  of  wounds,  bruises,  and  contusions 
may  give  rise  to  the  disease ;  tumors,  abscesses  and 
inflammatory  changes  in  the  vicinity  of  the  nerve,  com- 
pression of  the  nerve,  whether  from  external  or  inter- 
nal causes,  may  give  rise  to  the  disturbance.  Rheumatic 
thickening  of  the  sheath,  from  exposure  to  cold,  is  a 
very  common  cause.  Neuritis  sometimes  occurs  after 
eruptive  fevers  or  diphtheria,  or  is  the  result  of  syphilis. 

Symptoms. — Pain  is  the  most  prominent  symptom 
of  neuritis,  at  least  in  the  patient's  opinion.  There 
may  be  fever  with  chills  before  the  pain  is  felt ;  but  this 
is  not  very  common.  The  pain  is  often  severe,  of  a 
burning  character,  sometimes  more  aching  in  nature ; 
it  is  felt  in  the  course  of  the  peripheral  distribution  of 
the  nerve  ;  the  limb  is  hypersesthetic,  sometimes  a  very 
slight  touch  causing  distress ;  there  is  always  tender- 
ness over  the  course  of  the  nerve,  especially  where  it 
is  superflcial.  The  pain  is  continuous,  but  with  sea- 
sons of  exacerbation  ;  often  is  most  severe  at  night. 

When  the  nerve  is  seriously  affected,  the  sense  of 
touch  is  much  diminished  or  lost ;  even  in  rather  mild 
cases  there  is  a  dullness  of  that  sense,  yet  the  anses- 


SIMPLE  NEURITIS.  263 

thetic  part  may  be  very  tender,  and  a  slight  pressure 
may  cause  pain. 

The  pain  may  prevent  motion,  but  subsequently  the 
muscles  to  which  the  nerve  is  distributed  lose  their 
power,  are  paralyzed,  and  undergo  more  or  less  wast- 
ing according  to  the  amount  of  change  in  the  nerve. 
When  the  nerve  is  entirely  destroyed,  the  motor  pa- 
ralysis is  complete,  the  atrophy  extreme,  with  the  reac- 
tion of  degeneration. 

When  the  muscles  are  only  partially  paralyzed  there 
may  be  tremor,  very  closely  resembling  the  tremor  of 
sclerosis  ;  or  more  extensive  spasm  and  twitching  may 
occur. 

After  the  acute  symptoms  have  subsided,  or  from 
the  beginning  in  other  cases,  a  cJironic  neuritis  may  be 
recognized.  The  symptoms  are  the  same,  though  per- 
haps less  severe  than  in  the  acute,  except  that  there 
is  no  fever,  and  at  length  other  symptoms  are  added. 
The  pain  may  have  less  of  the  burning  character,  but 
be  quite  as  wearing ;  often,  however,  it  is  only  moder- 
ate in  degree,  and  in  very  mild  cases  is  not  present  con- 
tinuously ;  it  is  excited  or  increased  by  use  of  the  limb. 
The  numbness  and  pricking  are  the  same  as  when  the 
disease  is  acute.  There  is  always  tenderness  over  the 
affected  nerve,  which  is  often  swollen. 

The  motor  disturbance  is  the  same  as  in  acute  neu- 
ritis, but  may  be  more  slowly  developed  ;  the  reaction 
of  degeneration  is  proportionate  to  the  amount  of  atro- 
phy ;  when  the  disease  is  very  slight,  the  electrical  irri- 
tability may  be  increased.  Tremor,  as  in  sclerosis,  is 
more  common  than  in  the  acute  form. 

Trophic  changes  in  other  than  the  muscular  tissue 
are  almost  always  noticed.  These  have  been  studied 
especially  by  Mitchell,  and  consist  in  herpetic,  vesic- 
ular, and  other  eruptions,  atrophy  of  the  skin,  "glos- 
sy skin,"  with  a  peculiar  hypersesthetic  condition, 
"causalgia."  The  nails  may  become  clubbed,  brittle; 
their  growth  is  less  rapid.    The  hair  is  brittle,  may  fall 


264       DISEASES  OF  THE  PERIPHERAL  NERVES. 

off,  or  may  grow  abnormally  long,  or  it  may  become 
white. 

Acute  neuritis  may  be  of  sliort  duration,  the  nerve 
soon  recovering  its  normal  condition.  Chronic  neuri- 
tis persists  for  many  weeks  or  months,  and,  when  it 
has  apparently  disappeared,  the  symptoms  are  easily 
excited  again. 

Neuritis  shows  a  tendency  to  extend  toward  the 
nerve-centers,  or  to  pass  to  adjoining  nerves.  Not  in- 
frequently the  inflammation  extends  until  it  seems  as 
if  all  the  nerves  of  the  limb  were  affected.  I  have 
seen  this  in  the  arm  rather  than  the  leg,  jperhaps  be- 
cause the  patients  could  not  or  would  not  give  the  limb 
the  needed  rest.  This  extension  is  not  always  by  con- 
tinuity ;  the  inflammation  may  Jump  over  a  stretch  of 
healthy  tissue.  The  disease  may  extend  to  the  cord, 
and  thereby  death  may  result. 

Prognosis. — The  patient's  life  is  only  rarely  threat- 
ened when  the  disease  extends  to  the  nerve-centers. 
Perfect  recovery  is  possible  when  the  disease  has  con- 
tinued comparatively  long,  if  the  changes  have  not 
become  too  extensive,  and  even  serious  and  severe 
cases  may  do  well.  Many  times,  however,  the  tro- 
phic changes  in  muscles  and  other  structures  are  so 
considerable  that  a  complete  recovery  of  function  is 
not  possible  ;  the  symptoms  of  neuritis  disappear,  but 
the  parts  remain  partially  helpless.  In  less  favorable 
cases  more  or  less  pain  may  be  felt  at  intervals,  show- 
ing that  the  nerve-fibers  are  still  subject  to  irritating 
influences.  A  relapse,  or  a  second  attack,  is  not  uncom- 
monly the  result  of  comparatively  slight  imprudence 
in  over-exertion  or  exposure. 

Teeatmeistt. — Rest  is  of  great  importance  in  both 
acute  and  chronic  neuritis.  The  limb  affected  should 
be  kept  quiet ;  if  necessary,  the  patient  should  be  con- 
fined to  bed.  If  the  arm  is  affected,  it  may  be  well  to 
secure  a  splint  lightly  to  the  limb. 

In  acute  cases,  cold  may  be  applied  constantly  over 


SIMPLE  NEURITIS.  265 

the  seat  of  the  inflamed  nerve,  A  rubber  bag,  so  ar- 
ranged that  a  stream  of  cold  water  will  flow  continu- 
ously through  it,  is  convenient. 

Galvanism  has  been  advised,  and  is  of  benefit  in 
some  cases.  It  is  not  likely  to  do  much  good  in  acute 
cases,  and  in  chronic  is  often  less  useful  than  blister- 
ing ;  it  may  even  increase  the  pain  and  aggravate  the 
symptoms.  After  recovery  is  fairly  established,  and 
the  pain  has  ceased,  electricity  will  be  of  value  in  re- 
storing the  use  of  the  partially  paralyzed  muscles. 

In  subacute  and  chronic  cases  the  most  efficient 
means  is  blistering,  A  blister  the  size  of  a  ten-cent 
piece  or  a  quarter  should  be  put  over  the  tender  points 
in  the  course  of  the  nerves.  If  several  nerve-trunks  are 
affected,  one  after  the  other  may  be  thus  treated.  It  is 
not  well  to  apply  many  at  one  time.  Sometimes  the 
pain  is  worse  until  a  day  or  two  after  the  blister  is 
drawn,  when  a  marked  relief  will  be  experienced  ;  the 
blister  seems  to  be  of  most  benefit  while  the  raw  sur- 
face is  healing ;  for  this  reason  the  healing  should  be 
favored  as  much  as  possible  by  not  removing  the  cuti- 
cle, and  by  avoidance  of  irritating  ointments  and  fric- 
tion. 

It  may  be  necessary  to  control  pain  by  giving  mor- 
phia or  other  narcotics.  A  four-per-cent  solution  of 
carbolic  acid,  applied  to  the  limb  on  compresses,  may  be 
useful  in  relieving  the  pain. 

Salicylic  acid  in  rheumatic  cases,  iodide  of  potas- 
sium, quinine  in  rather  large  doses,  and,  later,  cod-liver 
oil  and  other  tonics,  would  be  of  value. 

During  convalescence,  when  pain  has  nearly  or  quite 
ceased,  electricity,  massage,  passive  exercise,  or  the 
Swedish  movement,  may  be  used  to  restore  function 
and  increase  the  nutrition  of  the  limb. 

In  syphilitic  neuritis,  of  course  the  specific  treat- 
ment should  be  used. 


266       DISEASES  OF  TEE  PERIPHERAL  NERVES. 
MULTIPLE  NEURITIS  (Disseminated  Neuritis). 

Pathological  Aistatomy.  —  The  affected  nerves 
show  no  special  gross  change  ;  they  do  not  seem  to  be 
enlarged  or  congested.  Under  the  microscope  the 
nerve-fibers  are  found  to  have  undergone  extensive 
changes.  There  is  inflammation,  and  below  this  the 
medullary  sheaths,  with  the  axis  cylinders,  are  seg- 
mented, then  divided  into  smaller  granular  masses,  and 
finally  these  are  absorbed.  The  nuclei  increase  in 
numbers.  There  is  only  a  moderate  increase  of  the 
interstitial  tissue. 

The  muscles  show  changes  due  to  degeneration— a 
granular  appearance ;  fat  is  deposited  between  their 
fibers,  which  may  undergo  simple  atrophy ;  their  nu- 
clei are  multiplied, 

Etiology. — Exposure  to  cold  and  over-exertion 
are  considered  important  as  causes.  Certainly  many 
patients  refer  their  disease  to  "  catching  cold. "  Cas- 
pari  suggests  that  multiple  neuritis  may  be  an  infec- 
tious disease. 

It  has  been  thought  by  several,  who  have  had  op- 
portunity to  observe  it,  that  heri-heri,  or  JcaTc-ke,  is  a 
multiple  neuritis.  Scheube  has  carefully  examined 
twenty  cases,  post-mortem,  and  reaches  this  conclu- 
sion. 

Symptoms. — The  disease  may  begin  with  fever,  pre- 
ceded or  not  by  a  chill,  or  the  fever  may  be  absent. 
The  pulse  is  habitually  rapid  throughout  the  disease. 
Pain  and  stiffness  in  the  limbs  are  usually  first  to  at- 
tract the  patient's  attention — usually  the  legs,  some- 
times the  arms,  being  first  affected.  Any  effort  to  move 
the  limbs  increases  the  pain,  which  may  then  be  most 
acutely  felt  about  the  joints.  A  hypersesthesia  of  the 
muscles  increases  the  resemblance  to  rheumatic  fever. 

The  pain  is  almost  constant,  may  be  extremely  se- 
vere, is  attended  with  a  sensation  of  tingling  or  prick- 
ing, or  may  be  of  a  burning  character,  as  if  very  hot 


MULTIPLE  NEURITIS.  267 

water  were  applied  to  the  limb.  Sometimes  the  pain 
seems  to  be  confined  to  the  course  of  the  diseased  nerve 
or  nerves,  or  it  is  generally  diffused  over  the  region  to 
which  the  nerve  is  distributed.  ISTot  only  is  there  gen- 
eral hypersesthesia  to  pressure,  but  the  course  of  the 
nerve  is  tender,  and,  upon  pressure  over  the  nerve- 
trunks,  the  pain  is  increased  in  the  limb  also. 

The  sense  of  touch  is  diminished  in  the  affected 
parts ;  especially  is  this  noticed  by  the  patient  after 
the  pain  has  partially  or  entirely  disappeared. 

The  muscles  supplied  by  the  affected  nerves  are  par- 
tially paralyzed  early  in  the  course  of  the  disease,  yet 
motion  is  restricted  more  by  the  pain  excited  than  by 
the  weakness ;  later  there  may  be  total  paralysis  of 
single  muscles  or  groups  of  muscles. 

The  cutaneous  reflexes  are  absent  in  about  half,  and 
the  patellar  tendon  reflex  is  absent  in  more  than  nine 
tenths  of  the  cases  ;  the  latter  is  very  late  in  returning. 

The  limbs  are  more  or  less  flexed,  and  this  position 
may  be  maintained  by  contracture  of  the  muscles  ;  then 
passive  extension  is  very  painful. 

The  muscles  waste  and  show  the  reaction  of  degen- 
eration. This  change  may  occur  very  rapidly  in  acute 
cases.  Abnormal  positions  of  the  fingers  and  limbs 
may  be  caused  by  the  wasting,  as  in  other  cases  of  mus- 
cular atrophy. 

Trophic  changes  may  be  seen  in  the  skin,  occasion- 
ally there  is  oedema  of  the  limbs,  and  sometimes  ex- 
cessive sweating. 

The  inflammation  extends  more  or  less  rapidly  from 
nerve  to  nerve,  not  following  any  regular  order,  though 
the  disease  is  usually  roughly  symmetrical,  both  legs 
or  both  arms  being  affected  at  about  the  same  time. 
The  different  muscles  are  not  equally  paralyzed  on  the 
two  sides. 

Mental  and  cerebral  symptoms  are  usually  wanting ; 
when  present,  they  have  seemed  to  be  due  to  some 
complication ;  the  suffering  has  seemed  to  give  rise  to  a 


268       DISEASES  OF  TEE  PERIPHERAL  NERVES 

hysterical  condition ;  occasionally  a  mild  nocturnal  de- 
lirium is  noticed. 

The  paralysis  may  extend  until  so  extensive  that 
life  is  threatened,  and  death  may  result  from  paralysis 
of  the  respiratory  nerves.  In  most  cases,  however, 
after  a  time  the  pain  and  tenderness  diminish  and  final- 
ly disappear,  leaving  the  ansesthesia  and  weakness. 
Recovery  is  slow,  delayed  by  contractions  of  the  limbs, 
and,  if  the  nerve-structures  have  been  seriously  dam- 
aged, it  may  never  be  complete. 

DiAGisrosis. — Multiple  neuritis  is  most  likely  to  be 
confounded  with  anterior  poliomyelitis,  progressive 
muscular  atrophy,  lead  paralysis,  and  rheumatic  fever. 

The  sensory  disturbances  distinguish  it  from  disease 
of  the  cells  of  the  anterior  cornua  of  the  cord ;  these 
and  the  marked  changes  in  electrical  reactions  will  dis- 
tinguish it  from  progressive  muscular  atro^^hy,  where 
there  are  only  very  slight  electrical  changes,  simple 
diminution  of  reaction,  and  rarely  if  ever  the  reaction 
of  degeneration.  Lead  paralysis  has  many  of  the  symp- 
toms of  multiple  neuritis ;  but,  as  a  rule,  the  sensory 
disturbance  is  less  severe ;  the  other  signs  of  lead-poi- 
soning and  the  elimination  of  lead  by  the  kidneys  un- 
der the  use  of  iodide  of  potassium  are  of  value  in  mak- 
ing a  diagnosis. 

It  is  only  at  the  very  beginning  that  neuritis  and 
rheumatic  fever  resemble  each  other ;  the  latter  is  ac- 
companied with  a  higher  temperature,  and  soon  the 
joint  affection  and  the  course  of  the  disease  will  make 
the  diagnosis  clear. 

Teeatmeft. — During  the  earlier  stages  of  the  dis- 
ease, salicylic  acid  or  the  salicylate  of  soda,  in  large 
doses,  is  apparently  of  most  value.  Bags  of  hot  water 
to  the  spine  have  seemed  to  relieve  the  pain  ;  hot  baths 
are  said  to  be  helpful.  Small  and  frequently  repeated 
doses  of  aconite  are  sometimes  of  value. 

The  chief  indication  at  first  is  to  relieve  pain.  Mor- 
phia should  be  given  as  freely  as  needed.    For  e^^ternal 


MULTIPLE  NEURITIS.  269 

use,  chloroform,  or  a  four-  to  five-per-cent  solution  of 
carbolic  acid,  may  be  found  serviceable.  A  subcutane- 
ous injection  of  a  two-per-cent  solution  of  carbolic  acid 
is  recommended  by  Caspar!.  If  the  disease  is  not 
widespread,  blisters  might  be  of  advantage. 

Rest  in  bed  is,  of  course,  necessary ;  massage  and 
passive  motion  should  not  be  attempted  till  after  the 
disease  has  come  to  a  standstill.  The  same  is  true  of 
electricity.  These  agents  are,  however,  of  great  value 
in  restoring  their  function  to  the  paralyzed  muscles ; 
the  galvanic  current  is  preferable  in  most  cases.  Mass- 
age and  passive  motion  should  be  used  systematically 
to  overcome  the  contractures  which  remain  after  the 
acute  symptoms  have  disappeared. 


CHAPTER  XXIII. 

NEUEALGIA. 

Valleix,  F.  L.  I.,  Guide  du  medecin  practicien,  1866,  t.  i,  p. 
693. — Anstie,  F.  E.,  Neuralgia  and  the  Diseases  that  resemble  it. 
London,  1871.— Trousseau,  Clinique  medicale.  Paris,  1865.  (Al- 
so New  Sydenham  Soc.'s  translation,  1868.)— Mitchell,  S.  Weir, 
The  Relations  of  Pain  to  Weather,  etc.  Am.  Jour,  of  the  Med.  Sci. , 
April,  1877,  p.  305,— Wood,  H,  C,  The  Trigeminal  Neuralgias. 
Med.  Record,  Oct.  27,  1877,  p.  673.— Seguin,  E.  C,  Report  on 
Aconitia  in  the  Treatment  of  Trigeminal  Neuralgia.  N.  Y.  Med. 
Jour.,  Dec,  1878. — Ibid.,  A  Contribution  to  the  Medicinal  Treat- 
ment of  Chronic  Trigeminal  Neuralgia.  N.  Y.  Med.  Record,  Jan. 
4,  1879. — Chapman,  John,  Neuralgia  and  Kindred  Diseases.  Lon- 
don, 1873. — V.  Pitha,  Prof.,  On  the  Diagnosis  and  Treatment  of 
Neuralgia.  Med.  Times  and  Gaz.,  1875,  ii,  pp.  356,  591.— Eulen- 
BURG,  Die  Osmiumssaurebehandlung  der  periph.  Neuralgien. 
Berl.  M.  Wochenschr.,  No.  7,  1884. — Alexander,  R.  G.,  Practi- 
cal Notes  on  Neuralgia  and  its  Treatment.  Lancet,  June  3,  1882, 
p.  908. — DUJARDIN  -  Beaumetz,  On  the  Treatment  of  Neuralgia. 
Med.  News,  April  14,  1883,  p.  405.— Seeligmuller,  A.,  Lehrbuch 
der  Krankheiten  der  peripheren  Nerven,  und  des  Sympathicus. 
Braunschweig,  1882. 

I^euralgia  is  the  name  given  to  an  affection  of  wMch 
the  chief  symptom  is  pain.  This  pain  is  of  variable 
intensity  and  character,  it  follows  the  course  of  the 
affected  nerve  and  its  branches,  occurs  in  paroxysms 
with  periods  of  more  or  less  perfect  remission  or  even 
intermission,  and  is  not  dependent  upon  any  discover- 
able organic  lesion. 

Symptoms. — The  essential  symptom  of  neuralgia  is 
pain,  which  may  be  confined  to  a  limited  region,  or 
may  follow  the  course  of  the  nerve  and  its  branches, 
even  radiating  into  other  nerve-districts.     The  char- 


NEURALGIA.  271 

acter  of  the  pain  varies ;  the  superficial  cutaneous 
branches  are  the  most  frequently  affected,  though  the 
pain  is  sometimes  deep-seated,  and  the  visceral  nerves 
may  suffer.  The  pain  may  be  very  light,  and  cause 
very  little  discomfort ;  or  may  be  severe,  lancinating, 
cutting,  tearing,  burning,  boring,  twisting.  Patients 
use  different  words  in  describing  the  attacks,  and  there 
is  probably  a  difference  in  the  character  of  the  pain, 
though  in  a  severe  paroxysm  one  is  scarcely  able  to 
make  a  very  nice  distinction,  and  so  the  patient  uses 
that  term  which  occurs  to  him  at  the  time  as  most  ex- 
pressive. 

Before  an  attack  of  neuralgia  the  patient  may  be 
conscious  of  impaii-ed  general  health  ;  or  there  may  be 
more  direct  warning  in  a  period  of  discomfort,  a  sense 
of  weariness,  of  weight,  or  tmgling,  or  some  abnor- 
mal sensation  in  the  parts  about  to  be  affected.  Slight 
twinges  of  pain,  which  are  really  less  severe  attacks, 
precede  the  more  severe  ;  twitching,  tremors,  and  slight 
loss  of  power,  may  be  among  the  prodromes.  Similar 
phenomena  may  precede  each  attack  of  neuralgia,  so 
that  the  patient  learns  to  anticipate  it. 

In  other  cases  the  pain  suddenly  bursts  out  and 
overwhelms  the  patient's  fortitude  by  its  severity  and 
its  unexpected  onset.  These  sudden  attacks  are  proba- 
bly rare  in  the  early  stage  of  the  disease,  but  are  less 
rare  after  several  attacks  have  followed  one  another 
with  intervals  of  entire  intermission. 

Between  the  paroxysms  there  may  be  less  severe 
pain,  which  is  then  more  frequently  of  an  aching,  burn- 
ing, or  pricking  character. 

The  duration  of  an  attack  may  vary  within  very 
wide  limits;  paroxysm  after  paroxysm  succeed  each 
other  with  almost  lightning-like  rapidity,  and  even  in 
the  intervals  the  pain  is  very  intense,  so  that  the  whole 
series  of  paroxysms  may  be  looked  upon  as  one  attack. 
At  another  time  there  is  only  one  sharp  sting  of  pain. 
The  attacks  may  recur  several  times  an  hour  or  day,  or 


2Y2       DISEASES  OF  THE  PERIPHERAL  NERVES, 

may  be  absent  for  days  or  months.  An  extended  pe- 
riod of  freedom  from  all  pain  is  rare  in  a  patient  very 
much  affected.  In  severe  cases  remissions  are  more 
common  than  intermissions.  The  first  attacks  are  often 
comparatively  light,  and  the  severity  of  the  pain  gradu- 
ally increases  as  the  attacks  multiply. 

The  pain  is  always  felt  either  at  one  point  of  a  nerve 
or  along  the  course  of  a  nerve.  Not  infrequently  a 
patient  unacquainted  with  anatomy  will  map  out  the 
affected  nerve  and  its  branches.  The  locality  of  the 
pain  may  be  different  in  the  different  attacks,  shifting 
perhaps  to  the  opposite  side  of  the  body.  When  the 
pain  always  affects  the  same  nerve,  there  is  a  strong 
probability  that  it  is  due  to  an  organic  lesion  of  that 
nerve. 

In  the  beginning  of  the  disease,  and  in  uncompli- 
cated cases  throughout,  there  is  no  elevation  of  tem- 
perature. 

When  one  nerve  has  been  long  the  seat  of  pain,  there 
is  usually  a  loss  of  acuteness  in  common  sensibility  of 
the  skin,  and  an  increase  in  acuteness  to  sensation  of 
pain.  Certain  points  become  tender,  so  that  a  very 
light  touch  is  painful.  These  points,  points  doulou- 
reux, were  specially  studied  by  Yalleix,  and  are  some- 
times named  from  him.  They  are  found  where  the 
nerve  passes  through  bony  canals,  or  through  fasciae, 
becoming  thus  superficial.  These  points  may  not  be 
painful  when  the  disease  has  but  recently  commenced  ; 
sometimes  they  are  entirely  wanting.  If  the  pain  is 
clearly  intermittent,  they  may  not  be  tender  to  pressure 
during  the  intermission.  It  is  not  uncommon  to  find 
the  spinous  processes  of  the  vertebrae,  between  which 
the  affected  nerves  pass,  painful  upon  pressure,  points 
apopliys  aires. 

The  pain  of  neuralgia  is  increased  by  all  motions  of 
the  affected  parts  ;  thus,  motions  of  the  Jaw  in  chewing, 
or  of  the  face  in  talking  and  laughing,  will  increase  the 
severity  of  facial  neuralgia ;  so  walking  will  render  the 


FEUEALGIA.  273 

suffering  more  severe  in  sciatica.  Necessarily,  there- 
fore, under  sucli  conditions,  neuralgia  will  interfere 
with,  motion. 

Besides  the  above  causes  of  immobility,  there  may 
be  actual  weakness  of  the  muscles,  a  partial  paralysis. 
Twitchings,  tremor,  and  even  more  severe  spasms  of 
the  muscles,  may  attend  the  paroxysm  as  well  as  pre- 
cede it. 

There  may  be  changes  in  the  circulation  or  the  nu- 
trition of  the  affected  parts.  The  arteries  are  at  first 
contracted,  and  the  skin  is  pale ;  later,  relaxation  of 
the  vessels  gives  rise  to  a  more  congested  appearance, 
and  there  may  even  be  a  tendency  to  cyanosis.  (Ede- 
ma is  sometimes  noticed  in  the  limbs  or  face.  The  se- 
cretions may  also  be  altered,  the  tears  flow  freely,  and 
the  saliva  and  urinary  secretions  are  abundant. 

Decided  trophic  changes  are  usual  in  old,  obstinate 
cases,  especially  in  neuralgia  of  the  limbs  ;  the  muscles 
are  wasted  more  than  can  be  explained  by  their  lack  of 
exercise.  This  wasting  has  been  explained  by  the 
changes  in  the  nerve  which  give  rise  to  the  pain,  peri- 
neuritis, or  by  supposing  a  change  in  the  circulation  of 
the  cord,  and  hence  disturbance  of  nutrition  in  the 
motor  cells  of  the  anterior  cornua. 

Cutaneous  eruptions,  herpes,  erythema,  pemphigus, 
urticaria,  and  psoriasis  may  be  found  among  the  com- 
plications of  neuralgia.  The  skin  may  become  thick- 
ened, and  the  hair  may  change  color. 

Except  in  severe  and  long-continued  cases,  the  gen- 
eral health  and  disposition  rarely  suffer.  Persistent 
and  extreme  pain,  however,  impairs  the  digestion,  dis- 
turbs sleep,  prevents  exercise,  taxes  the  endurance,  and 
at  length  there  is  evident  a  disturbance  of  the  general 
health  ;  the  temper  becomes  more  irritable  and  peevish, 
mental  power  may  be  weakened,  and  finally  there  may 
be  insanity.  This  is  rare,  as  the  patients  usually  quick- 
ly regain  health  when  there  is  even  temporary  relief 
from  pain. 

18 


274:       DISEASES  OF  THE  PERIPHERAL  NERVES. 
TRIFACIAL  NEURALGIA  (Prosopalgia) 

Is  one  of  tlie  most  common  forms  of  neuralgia.  As  the 
branches  of  the  fifth  nerve  pass  through  bony  canals 
they  are  much  more  readily  compressed  by  a  very  slight 
swelling  of  their  sheaths,  and  the  pain  thus  produced 
is  proportionately  severe. 

Exposure  to  cold,  decayed  teeth,  and  exostosis  are 
likely  to  be  among  the  causes  ;  but  disturbance  of  the 
stomach,  intestines,  generative  organs,  and  other  dis- 
tant parts,  may  give  rise  to  the  disease. 

The  symptoms  are  such  as  have  been  already  de- 
scribed. The  pain  is  often  excessive;  spasm  of  all  the 
muscles  of  the  affected  side  of  the  face  is  excited  by 
the  agony.  The  painful  points  are  the  palpebral,  at 
the  external  part  of  the  upper  eyelid ;  the  supra- 
orbital^ where  the  frontal  nerve  turns  up  over  the  edge 
of  the  brow  ;  the  nasal,  at  the  upper  part  of  the  nose ; 
the  malar ;  the  infra-orMtal,  at  the  point  of  emer- 
gence of  the  infra-orbital  nerve ;  the  mental,  where  the 
inferior  maxillary  nerve  ends  in  the  mental  and  passes 
out  from  the  foramen.  There  are  less  important  points 
mentioned:  the  ocular;  fhe  labial;  the  lingual;  the 
parietal,  which  is  common  with  the  cervico-occipital 
neuralgia.  The  points  apopTiysaires  are  found  over 
the  spinous  processes  of  the  first  and  second  cervical 
vertebrae  and  the  occipital  protuberance. 

The  conjunctiva  of  the  eye  on  the  affected  side,  and 
sometimes  of  the  opposite  eye,  may  be  deeply  con- 
gested, tears  may  fiow  freely,  and  the  nasal  mucous 
membrane  may  secrete  profusely.  The  pupil  is  often 
dilated. 

CERVICO-OCCIPITAL  NEURALGIA 

Is  seated  in  the  region  to  which  the  first  four  cervical 
nerves  (cervical  plexus)  are  distributed.  This  includes 
the  back  and  side  of  the  head  as  far  forward  as  the  ear, 
the  neck  and  apex  of  the  shoulder,  and  posterior  part 


L0R80-INTEEC0STAL  NEURALGIA.  275 

of  the  lower  Jaw.  The  painful  points  are  the  occipital, 
between  the  mastoid  process  and  the  first  vertebra ;  the 
mastoid,  over  that  process  close  to  the  ear  near  the  exit 
of  the  seventh  nerve ;  the  parietal,  in  common  with 
trifacial  neuralgia,  and  sometimes  the  rim  of  the  ear  is 
tender.  The  points  apophysaires  are  over  the  four 
upper  cervical  vertebrge. 

It  is  important  not  to  mistake  the  pain  caused  by 
caries  of  the  upper  cervical  vertebrae  for  this  form  of 
neuralgia. 

When  the  nerves  of  the  brachial  plexus  are  involved 
we  have  cermco-hracMal  neuralgia.  This  is  more  fre- 
quently traumatic  in  origin.  The  painful  points  are 
found  in  the  axilla,  over  the  median  nerve  at  the  elbow, 
the  ulnar  just  above  the  elbow,  the  radial  where  it  fol- 
lows round  the  humerus,  at  the  lower  angle  of  the 
scapula,  and  at  the  lower  end  of  the  ulna.  The  points 
apophysaires  are  over  the  lower  cervical  and  upper 
dorsal  vertebrae. 

Many  times  there  is  really  chronic  neuritis  as  cause 
of  the  pain. 

DORSO-INTERCOSTAL  NEURALGIA 

Is  a  very  frequent  form.  The  thoracic  nerves  are  in- 
volved ;  it  is  rather  more  frequent  on  the  left  side  ;  it  is 
one  of  the  accompaniments  of  various  pulmonary  dis- 
eases ;  is  common  in  phthisis.  Herpes  zoster  is  very 
common  around  the  chest ;  it  may  be  excited  by  dis- 
turbances of  the  abdominal  viscera,  especially  of  the 
stomach. 

The  painful  points  are  found  just  to  the  side  of  the 
vertebrae ;  then  near  the  center  of  the  course  of  the  in- 
tercostal nerves  ;  and,  anteriorly,  the  region  of  terminal 
expansion,  as  Trousseau  calls  it.  In  tracing  the  nerve, 
the  curvilinear  course  of  the  ribs  should  not  be  forgot- 
ten. The  points  apophysaires  are  found  over  the  ver- 
tebrae corresponding  with  the  affected  nerve. 

Infra-mammary  neuralgia  is  one  variety  of  inter- 


276       DISEASES  OF  THE  PERIPHERAL  NERVES. 

costal,  wMcli  gives  mucli  annoyance  and  causes  nmcli 
suffering,  exciting,  also,  fears  in  the  patient  of  inflam- 
mation of  tlie  breast. 

When  intercostal  neuralgia  is  severe,  the  respiration 
is  disturbed,  rapid,  and  painful ;  the  pain  radiates  to 
the  arm  ;  there  is  palpitation,  and  angina  pectoris  may 
be  closely  simulated. 

LUMBO-ABDOMINAL   NEURALGIA 

Is  the  name  given  to  the  disease  when  the  crural  plexus 
is  the  seat  of  pain.  The  painful  points  are  near  the 
spinal  column  ;  just  above  the  crest  of  the  ilium,  near 
its  center  ;  above  the  pubis  ;  near  the  lower  part  of  the 
rectus  muscle  ;  there  may  be  points  in  the  vagina  or 
about  the  scrotum  ;  over  the  anterior- superior  spinous 
process ;  over  the  crural  nerve  as  it  passes  out  from  un- 
der Poupart'  s  ligament ;  on  the  inside  of  the  knee-pan ; 
and  over  the  saphenous  nerve  in  front  of  the  ankle. 

Sometimes  congestion  and  haemorrhages  from  the 
uterus  and  vagina  seem  to  depend  upon  this  neuralgia. 
The  pain  may  lead  to  a  suspicion  of  uterine  disease. 
Lumbago  may  be  distinguished  by  the  fact  that  mo- 
tion causes  pain,  which  is  absent  during  complete  quiet. 
The  pain  caused  by  renal  calculi  may  be  mistaken  for 
neuralgia. 

SCIATICA 

Is  one  of  the  most  common,  most  rebellious  of  neural- 
gias ;  it  is  rather  more  frequent  in  men.  In  the  ma- 
jority of  cases  there  is  a  neuritis.  Between  the  par- 
oxysms of  pain  there  is  usually  an  aching  or  burning 
sensation  ;  a  heavy,  bruised  feeling.  Exertion  will  of- 
ten cause  a  relapse. 

The  painful  points  are  :  near  the  sacrum  ;  where  the 
nerve  emerges  from  the  pelvis  ;  near  the  great  trochan- 
ter of  the  femur  (Erb  considers  this  the  most  constant) ; 
at  the  lower  border  of  the  gluteus  muscle  ;  in  the  pop- 
liteal space  ;  frequently  the  whole  course  of  the  nerve 
in  the  thigh  is  tender,  and  it  can  be  felt  to  be  enlarged ; 


SCIATICA.  277 

just  below  the  head  of  the  fibula ;  behind  the  outer 
ankle. 

Wasting  of  muscular  tissue  of  the  leg  is  not  uncom- 
mon in  cases  of  long  standing. 

j^TiOLOGY. — Anstie  considered  every  case  of  neu- 
ralgia to  be  one  of  debility.  This  is  somewhat  too 
sweeping  a  statement,  yet  it  is  true  of  most  patients 
suffering  from  this  affection  that  they  are  below  par  in 
physical  or  nervous  strength. 

Heredity  is  an  important  factor  in  the  aetiology  of 
neuralgia,  A  large  proportion  of  the  patients  are  born 
wdth  less  than  the  normal  nervous  stamina  ;  the  parents 
may  not  have  neuralgia,  but  the  children  have  less  than 
normal  strength  and  vigor.  Much  might  be  written  on 
this  division,  but  it  is  scarcely  necessary. 

Women  are  more  subject  to  some  forms  than  men  ; 
some  authors  consider  that  the  majority  of  patients  are 
women,  and  this  is  probably  true,  though  Axenfeld 
says  the  difference  is  less  than  is  usually  supposed. 

Children  rarely  have  neuralgia.  The  most  suscepti- 
ble age  is  middle  life.  The  more  marked  the  heredi- 
tary tendency,  the  earlier  the  disease  will  be  likely  to 
appear. 

It  is  necessary  only  to  mention  that  a  predisposition 
to  neuralgia  may  be  fostered,  or  even  developed,  by  hy- 
gienic surroundings,  by  overwork,  by  anxiety,  grief, 
etc.  These  influences  are  much  the  more  powerful  in 
youth,  yet  do  not  lose  their  power  in  adult  years. 

Acute  and  chronic  disease  may  bring  the  system 
into  such  a  state  of  anaemia  or  debility  as  to  greatly 
favor  an  outbreak  of  neuralgia. 

Among  exciting  causes,  "  catching  cold "  maybe 
the  most  frequent.  Exposure  to  wet  and  cold  is  often 
mentioned  by  patients  as  the  cause,  and  probably  with 
truth.  In  such  cases  there  is  many  times  a  rheumatic 
thickening  of  the  nerve-sheath,  and  the  disease  is  really 
a  neuritis.  It  is  not  always  possible  to  recognize  this 
by  the  symptoms.    The  nerves  most  exposed  to  this 


278       DISEASES  OF  THE  PERIPHERAL  NERVES. 

injurious  influence  are  those  of  the  face,  the  sciatic, 
and  less  frequently  those  of  the  arms.  Many  patients 
suffer  from  sciatica  after  sitting  on  a  stone  or  a  metallic 
seat. 

Injuries  of  nerves  or  in  their  vicinity  may  be  a  cause 
of  the  disease.  A  slight  injury  may  give  rise  to  neu- 
ralgia only  after  months  or  years.  Sometimes  in  such 
cases  a  change  in  the  sheath,  a  thickening,  has  been 
slowly  taking  place,  until  at  last,  either  spontaneously 
or  as  the  result  of  a  forgotten  exposure,  the  attack  of 
pain  follows. 

Tumors,  exostoses,  caries  of  teeth,  disease  in  tho- 
rax or  pelvis — these  and  other  changes  near  nerves,  by 
pressure  or  extension  of  inflammation,  may  cause  pain, 
and  the  exciting  cause  may  not  be  discovered,  owing  to 
its  hidden  location.  Such  cases  are  not,  properly  speak- 
ing, cases  of  neuralgia,  yet  the  diagnosis  of  the  true 
cause  of  the  pain  may  be  impossible. 

Neuralgia  may  be  excited  in  a  reflex  way  by  dis- 
eases of  the  viscera ;  this  is  especially  so  in  regard  to 
the  genito-urinary  and  digestive  organs,  and  in  regard 
to  caries  of  the  teeth. 

Several  poisons,  as  mercury,  copper,  lead,  alcohol, 
and  tobacco,  are  both  predisposing  and  exciting  causes ; 
the  same  may  be  said  of  malarial  influences.  Syphilis 
is  an  active  agent  in  many  instances,  but  not  so  often  a 
cause  of  neuralgia  as  of  headache. 

Pathogeistesis. — From  the  definition  of  neuralgia,  it 
is  evident  that  there  can  be  no  special  pathological 
change  in  the  nerves.  Many  times,  doubtless,  neuritis 
is  called  neuralgia,  and  that  name  is  given  to  other  con- 
ditions where  organic  changes  are  found.  It  is  proba- 
ble that  very  many  cases  of  neuralgia  ought  to  have 
another  name ;  but  this  is  the  result  of  ignorance  or 
carelessness  on  the  part  of  the  observer. 

Anstie  advocated  that  every  case  of  neuralgia  is 
in  reality  a  case  of  ansemia,  of  the  spinal  centers,  with 
atrophy  of  the  posterior  nerve-roots.     Chapman  claims 


NEURALGIA.  2Y9 

that  congestion  of  the  spinal  cord  is  the  cause  of  the 
pain. 

The  truth  is  that  we  do  not  know  definitively  the 
nature  of  this  affection.  It  would  be  easy  to  quote  au- 
thors to  show  the  varying  views  held  in  regard  to  this 
subject,  but  it  would  be  of  doubtful  advantage. 

Diagnosis. — Erb  gives  six  characteristic  symptoms 
of  neuralgia :  1.  The  pain  is  limited  to  a  definite  nerve- 
path,  or  area  of  distribution,  and  is  usually  unilateral. 
2.  Without  any  clear  reason,  the  pain  is  either  inter- 
mittent or  distinctly  remittent.  3.  The  pain  is  very 
peculiar  and  acute.  4.  Certain  spots  in  the  course  of 
the  nerve,  or  in  the  area  of  its  distribution,  are  very 
sensitive  to  pressure.  5.  The  pain  is  associated  with 
certain  sensory,  motor,  vaso-motor,  and  secretory  phe- 
nomena. 6.  The  pain  is  not  accompanied  by  any  in- 
flammatory or  local  symptoms,  or  any  general  disturb- 
ance of  health  at  all  corresponding  with  the  amount  of 
subjective  disorder. 

These  six  diagnostic  marks  are  only  presumptive  of 
neuralgia.  A  very  large  proportion  of  cases  are  proba- 
bly neuritis,  and  it  may  be  as  well  to  recognize  the  fact 
in  practice. 

The  pains  of  locomotor  ataxia  are  very  much  the 
same  as  those  of  neuralgia,  and  it  is  necessary  to  bear 
this  in  mind. 

Caries  of  the  vertebrae  may  give  rise  to  pain  which 
can  be  easily  mistaken  for  neuralgia  ;  the  same  is  true 
of  other  diseases  of  the  spine  or  spinal  membranes,  of 
cerebral  lesions,  and  of  malignant  growths  in  the  tho- 
racic and  abdominal  cavities.  In  all  these  cases  a  care- 
ful study  of  symptoms  may  lead  to  a  correct  diagnosis  ; 
but  without  this,  serious  mistakes  must  be  made. 

Peogjstosis. — Unless  there  is  a  neuritis  or  a  morbid 
growth  pressing  upon  the  nerve,  recent  cases  are  usu- 
ally readily  relieved ;  but  there  is  a  great  probability 
of  return.  The  greater  the  number  of  attacks,  and  the 
more  localized  the  pain,  the  less  probable  is  relief,  be- 


280       DISEASES  OF  TEE  PERIPHERAL  NERVES. 

cause  under  such,  circumstances  there  is  almost  always 
a  neuritis  or  a  perineuritis.  The  most  rebellious  cases 
are  those  affecting  the  fifth  and  sciatic  nerves. 

Treatment. — In  neurotic  subjects  the  treatment  of 
neuralgia  should  begin  before  the  pain  appears — that 
is,  much  can  be  done  to  prevent  its  development.  The 
young  child  should  be  fed  and  educated,  its  habits 
formed  with  si^ecial  regard  to  the  possible  occurrence 
of  nervous  disorders.  This  regimen  should  be  all  the 
more  carefully  followed  after  the  affection  has  appeared. 
Light,  air,  exercise,  and  food  are  necessary  in  large  meas- 
ure. Over-feeding  is  sometimes  of  great  value ;  fre- 
quent feeding,  hourly,  is  one  means  of  inducing  the 
system  to  receive  more  than  it  would  from  the  usual 
number  of  meals. 

So  far  as  possible,  all  causes  should  be  avoided ; 
warm  clothing  will  aid  much  ;  keep  the  feet  dry. 

Any  disease  which  may  give  rise  to  neuralgia  should, 
of  course,  be  treated ;  this  is  self-evident,  yet  easily 
forgotten  in  the  presence  of  the  pain  of  an  attack. 
Teeth  should  be  looked  after.  Dyspeptic  or  other  vis- 
ceral disturbance,  and  uterine  disorders,  attended  to. 
Alcohol  and  tobacco  should  be  stopped. 

It  is  scarcely  necessary  to  mention  that  metallic  poi- 
sons should  be  eliminated  if  possible.  In  syphilitic 
patients  a  corresponding  treatment  must  be  followed. 

Internally,  quinine  is  often  of  benefit,  not  only  in 
cases  due  to  malarial  poisoning,  but  where  there  is  no 
such  taint.  In  recent  cases,  given  in  moderately  large 
doses,  five  grains  every  hour  until  the  head  aches  or 
the  ears  are  affected,  it  will  frequently  cut  the  attack 
short.  It  is  also  useful  as  a  tonic  to  prevent  recur- 
rence. Anstie  found  it  useful  in  affection  of  the  oph- 
thalmic division  of  the  fifth  nerve. 

Cod-liver  oil,  or  other  form  of  fat,  cream,  or  butter, 
is  very  valuable.  Many  patients  find  the  oil  disagree- 
able. Begin  with  half  or  quarter  of  a  teaspoonful,  to 
which  a  little  salt  may  be  added ;  continue  this  dose, 


NEURALGIA.  281 

after  meals,  until  there  is  no  regurgitation  of  the  fumes 
of  the  oil ;  then  the  dose  can  be  rapidly  increased  to  a 
tablespoonful.     Phillips's  emulsion  is  very  palatable. 

Iron  in  its  various  preparations  is  indicated,  espe- 
cially in  anaemic  and  chlorotic  subjects.  The  tincture 
of  the  chloride  is  one  of  the  most  valuable  forms.  An- 
stie  recommends  very  highly  a  mixture  of  this  with 
strychnia,  ten  minims  of  the  iron  tincture  with  -^  grain 
of  the  strychnia.  The  soluble  saccharated  oxide  of  iron, 
in  doses  of  half  a  teaspoonf  ul,  is  a  very  pleasant  prepa- 
ration. 

Arsenic  is  valuable  in  the  same  cases  as  the  iron  ;  it 
is  also  useful  in  malarial  cases. 

Iodide  of  potassium,  or  the  syrup  of  hydriodic  acid, 
is  useful  not  only  in  syphilitic  neuralgia,  but  also  in 
rheumatic  ;  colchicum  may  help  in  such  cases,  though 
the  bowels  should  not  be  too  strongly  acted  upon. 

Phosphorus  has  been  very  highly  praised,  especial- 
ly by  many  English  physicians.  Mr.  Thompson  ad- 
vised it  in  large  doses,  not  less  than  -^  grain ;  he  ad- 
vised j3g.  grain  every  four  hours  ;  after  six  doses,  -^  grain 
at  the  same  interval.  After  forty-eight  hours,  if  no  re- 
sult, he  thinks  some  good  may  be  effected  by  increas- 
ing the  dose  still  further.  This  dose  rarely  causes  trou- 
ble, yet  occasionally  a  patient  is  unusually  susceptible, 
and  acute  poisoning  has  been  observed ;  caution  is, 
therefore,  necessary. 

Gelsemium,  fluid  extract,  in  ten-  to  twenty-minim 
doses,  or  tincture,  in  half-drachm  doses,  is  very  service- 
able in  facial  neuralgia,  and  perhaps  in  intercostal  and 
ovarian.  The  preparations  of  this  drug  are  sometimes 
inert.  The  dose  may  be  repeated  every  half -hour,  but 
it  is  prudent  not  to  give  more  than  three  doses  so  near 
one  another. 

Croton  chloral  has  been  used  in  facial  neuralgia  with 
very  good  results  by  many  ;  but  I  have  never  seen  any 
special  benefit  from  it. 

Aconitia  is  a  very  valuable  drug ;   it  is  especially 


282       DISEASES  OF  THE  PERIPHERAL  NERVES. 

useful  in  angina  pectoris,  in  intercostal  and  facial  neu- 
ralgia, bnt  is  of  benefit  in  any  form  of  reflex  or  consti- 
tutional neuralgia.  The  pure  alkaloid,  made  by  Du- 
quesnil,  crystallized,  should  be  used,  or  the  effect  will 
be  uncertain.  The  dose  varies  from  ^^  to  -j^-^  grain. 
Dr.  E.  C.  Seguin  recommends  the  following  formula  : 

^  Aconitise  (Duquesnil's) gr.  ^^  -  i ; 

fr'fr\  aafl3j; 

Alcohol     i  •" 

Aq.  menth.  pip q.  s.  ut  ft.  fl  §  ij.    M. 

S.  A  teaspoonf  ul  two  or  three  times  a  day,  on  an  empty 

stomach. 

This  may  be  given  even  more  frequently,  as  often  as 
every  two  hours,  if  the  effects  are  carefully  watched ; 
so  soon  as  the  pulse  is  affected,  or  there  is  tingling  of 
the  lips,  tongue,  or  fingers,  the  drug  must  be  discon- 
tinued. 

Fereol  found  sulphate  of  copper,  '05  to  '10,  of  value 
in  epileptiform  neuralgia. 

Other  drugs  that  have  been  used  are  chloride  of 
gold  and  sodium,  nitrite  of  amyl,  chloride  of  ammo- 
nium, strychnia,  which  is  praised  by  Anstie,  and  phos- 
phide or  oxide  of  zinc. 

During  the  attack  of  pain,  to  relieve  the  distress  it 
may  be  necessary  to  use  morphia  or  other  preparation 
of  opium.  Morphia  subcutaneously  is  the  most  effica- 
cious ;  but  care  is  needed  lest  the  morphia  habit  should 
be  formed.  In  old  and  obstinate  cases  the  smallest 
dose  which  will  relieve  the  pain,  yV  or  ^  grain,  should 
be  used  only  when  it  is  necessary  to  give  such  relief. 
In  recent  cases  one  large  dose  will  sometimes  work  a 
cure. 

Atropia  subcutaneously  will  frequently  give  as  much 
relief  as  morphia ;  -^  grain  is  usually  the  largest  dose 
necessary.  Anstie  recommends  atropia,  especially  for 
ophthalmic  neuralgia. 

Chloroform,  in  doses  of  five  to  ten  minims,  injected 


NEURALGIA.  283 

under  the  skin  in  the  vicinity  of  the  affected  nerve, 
often  gives  relief. 

Schultz  nsed  carbolic  acid,  two  to  one  hundred  of 
distilled  water,  subcutaneously,  injecting  from  a  quar- 
ter of  a  drachm  to  a  drachm  of  the  solution. 

Eulenburg  injected  a  one-per-cent  solution  of  osmic 
acid  with  benefit  in  recent  cases,  which  were  probably 
neuritic  or  perineuritic. 

The  subcutaneous  injection  of  a  drachm  of  hot  wa- 
ter near  the  nerve — of  course  not  so  hot  as  to  scald  the 
tissues — will  frequently  give  as  much  relief  as  small 
doses  of  morphia.  Acupuncture,  passing  a  needle  into 
the  skin  until  the  point  is  near  the  nerve,  will  give 
relief  in  many  cases.  The  needle  should  be  worked  in 
slowly  and  gradually,  as  near  the  nerve-trunk  as  pos- 
sible ;  if  its  point  can  just  touch  the  nerve,  which  may 
be  known  by  the  peculiar  sensation,  and  then  be 
slightly  withdrawn,  the  result  is  the  better.  This  prob- 
ably is  most  efficacious  in  recent  cases. 

Various  external  applications  will  soothe  the  pain 
during  an  attack,  and  render  the  use  of  morphia  less 
necessary.  Hot  water  is  useful ;  so,  too,  is  spirit  of 
turpentine.  Chloroform,  diluted  more  or  less  vdth  al- 
cohol, applied  on  a  piece  of  flannel  and  covered  with  a 
towel  wet  with  water,  eases  the  pain.  Grenerally  one 
part  of  chloroform  to  seven  of  water  is  a  good  mixture, 
though  one  stronger  is  often  better.  Yeratria  oint- 
ment can  bq  used,  but  aconite  is  better.  The  tincture 
of  aconite  may  be  used  freely,  or  the  ointment  may  be 
applied  over  the  affected  surface.  The  ointment  of 
aconitia,  if  made  with  Duquesnil'  s  aconitia  gr.  J  to  3  j 
lard,  will  be  stronger  than  the  regular  officinal  oint- 
ment. Care  must  be  taken  not  to  get  any  of  this  into 
the  eyes,  nose,  or  mouth,  and  not  to  rub  it  where  the 
skin  is  abraded.  The  person  who  applies  it  should 
not  use  his  uncovered  hands.  A  portion  half  as  large 
as  a  small  pea  is  sufficient  for  one  application.  I  know 
of  no  simple  external  application  of  equal  value. 


284       DISEASES  OF  THE  PERIPHERAL  NERVES. 

Blisters  over  the  tract  of  the  nerve,  especially  over 
the  points  douloureux  and  over  the  points  apopTiy- 
saire,  not  only  give  relief,  but  often  effect  a  cure.  The 
blisters  need  not  be  large  ;  an  inch  by  an  inch,  or  inch 
and  a  half,  is  sufficient.  They  may  need  to  be  repeated 
over  different  points,  or  near  the  same  spot. 

The  actual  cautery  over  the  same  spots  may  be 
even  more  valuable  than  blisters — may  give  immedi- 
ate relief  without  so  much  discomfort. 

Electricity  is  a  most  satisfactory  agent  in  many 
cases.  Sometimes  the  faradic,  applied  through  a  wire 
brush  to  the  seat  of  pain,  gives  immediate  relief.  The 
galvanic  current  passed  through  the  affected  nerve  or 
limb  is  usually  the  better.  It  should  be  used  daily, 
with  as  little  shock  or  variation  of  strength  as  possi- 
ble. 

Vibration  communicated  to  the  nerve  at  the  seat  of 
pain,  by  rapid  percussion  over  the  tender  points,  some- 
times gives  permanent  relief.  The  percussion  may  be 
made  by  means  of  rubber  balls  attached  to  handles,  or 
by  mechanical  contrivances. 

The  application  of  ice  by  means  of  the  rubber  ice- 
bag  to  the  spine,  either  a  portion  or  the  whole,  as  ad- 
vised by  John  Chapman,  is  soothing  and  grateful.  If 
properly  applied,  it  has  a  tendency  to  restore  warmth 
to  the  feet,  and  will  relieve  pain.  It  should  be  applied 
from  thirty  to  sixty  minutes  several  times  a  day.  Oc- 
casionally Chapman  uses  hot  water  over  the  upper  part 
of  the  spine  in  facial  neuralgia  with  hypersemia  or 
swelling  of  the  face. 

Surgical  operations  are  sometimes  needed  to  cure 
neuralgia ;  these  are  excision  of  portions  of  nerves, 
which  has  been  frequently  done  for  facial  neuralgia, 
and  stretching  of  nerves.  The  latter  is  of  compara- 
tively recent  date,  and  has  given  very  good  results. 
Patruban  has  tied  the  carotid  for  facial  neuralgia  with 
success  in  many  cases. 


CHAPTER  XXIV. 

LOCAL  AND  POST-FEBEILE  PARALYSES. 

Leyden,  Ueber  Refiexlalimuiig.  Vol7cmann''s  Sammlung,  No. 
2, 1870.— Feinberg,  Ueber  Reflexlahmung.  Berl.  M.  Wochen. ,  1871. 
— Panas,  De  la  paralysie  reputee  rheumat.  du  nerf  radial.  Arch, 
gen.,  1872. — Webber,  S.  G.,  Cases  of  Peripheral  Paralysis  :  their 
Causes  and  Nature.  Boston  Med.  and  Surg.  Jour.,  Dec.  18,  1873. 
— Bernhardt,  M.  ,  Zur  Pathologie  der  Radialisparalysen.  Arch, 
f.  Psych.,  iv,  1874,  p.  601. — Comegys,  Facial  Paralysis  and  Laby- 
rinthine Vertigo.  Med.  Record,  April  24, 1880,  p.  445.— Jofproy, 
A,,  Paralysie  radiale.  Theorie  de  la  compression.  Arch,  de 
physioL,  Mai,  1884,  p.  478. — Westphal,  C,  Ueber  eine  Affec- 
tion des  Nervensystems  nach  Pocken  und  Typhus.  Arch,  fur 
Psych.,  iii,  1872,  p.  376. — Landouzy,  L.,  Des  paralysies  dans  les 
maladies  aigues.  Paris,  1880. — Dejerine,  J.,  Eecherches  sur  les 
lesions  du  systeme  nerveux  dans  la  paralysie  diphtheritique. 
Arch,  de  phys.,  x,  1878,  p.  107.— Wood,  H.  C.,  Diphtheritic  Pa- 
ralysis. N.  Y.  Med.  Jour.,  Dec.  29,  1883,  p.  705.— KroD,  P.,  A 
Contribution  to  the  Pathology  of  Diphtheritic  Paralysis.  Med.- 
Chir.  Trans.,  vol.  Ixxxiv,  1883,  p.  133. 

PERIPHERAL  PARALYSIS. 

By  peripheral  paralysis  may  be  understood  paraly- 
ses wMch.  depend  upon  lesions  of  the  muscles  them- 
selves, or  the  nerves  after  they  leave  the  spinal  cord, 

Etiology. — Among  the  causes  may  be  mentioned 
injuries  from  falls  or  blows,  or  wounds  ;  pressure  upon 
nerves,  either  by  the  position  of  the  limbs  or  by  bur- 
dens carried  so  as  to  press  upon  the  nerves  ;  or  by  tu- 
mors, or  other  products  of  disease. 

Cold  is  a  common  cause  of  certain  forms  of  paraly- 
sis, so-called  rheumatic  paralysis.  Disease  of  neigh- 
boring parts,  even  when  the  nerves  are  not  directly 


286       DISEASES  OF  THE  PERIPHERAL  NERVES 

implicated,  may  give  rise  to  loss  of  motion,  as  in  Mp- 
disease,  there  is  loss  of  power  in  the  muscles  of  the 
leg,  which  may  be  attended  with  atrophy. 

Acute  diseases  are  many  times  followed  by  paraly- 
sis. Certain  poisons,  as  lead,  arsenic,  and  some  vege- 
table poisons,  cause  paralysis,  apparently  due  to  dis- 
turbance of  the  nerves.  The  same,  also,  may  be  said 
of  syphilis,  though  with  this  there  is  generally  a  for- 
mation of  new  tissue  around  the  nerves. 

Over-exertion  of  limbs,  exhaustion,  may  lead  to 
temporary  paralysis,  or  even  to  a  more  serious  and 
more  permanent  loss  of  motion. 

In  some  cases  the  paralysis  is  spoken  of  as  reflex, 
as  if  it  arose  from  disease  of  certain  organs  by  reflex 
action  through  the  spinal  cord.  It  is  rather  doubtful 
whether  such  paralyses  are  really  reflex,  as  is  claimed, 
and  do  not,  rather,  depend  upon  disease  either  of  the 
nerves  themselves  or  of  the  spinal  cord. 

Symptoms. — As  most  of  the  nerves  are  mixed 
nerves,  there  is  usually  loss  of  motion  and  disturb- 
ance of  sensation.  Sometimes  pains  or  peculiar  numb 
feelings  and  unpleasant  sensations  precede  any  loss  of 
power  ;  but  very  soon,  if  not  at  the  same  time  with  the 
disturbance  of  sensation,  the  patient  recognizes  that 
there  is  loss  of  power.  He  finds  that  he  can  not  per- 
form certain  acts  as  readily  as  formerly. 

The  nature  of  the  disturbance  of  motion  will  de- 
pend, of  course,  upon  which  nerve  is  affected.  If  the 
paralysis  is  not  complete,  the  ordinary  reflexes  may  not 
be  seriously  impaired ;  but  if  there  is  entire  loss  of 
either  motion  or  sensation,  both  the  superficial  and 
deep  reflexes  will  disappear. 

In  every  case  of  paralysis  depending  upon  a  lesion 
of  the  nerve  itself,  the  electrical  reactions  will  be  such 
as  have  been  described  under  the  name  of  the  reaction 
of  degeneration. 

Frequently  the  paralysis  is  attended  with  a  moder- 
ate degree  of  swelling  of  the  affected  limb,  due  to  a 


PERIPHERAL  PARALYSIS.  287 

loss  of  tone  in  the  blood-vessels  on  account  of  paralysis 
of  tlie  vaso-motor  nerves,  whicli  accompany  the  nerves 
of  motion  and  sensation.  For  the  same  reason  there 
may  be  at  first  a  rise  of  temperature  in  the  limb,  though 
subsequently  the  temperature  is  lowered,  and  the  limb 
may  have  a  cyanotic  appearance. 

Certain  trophic  changes  are  found  after  injuries  and 
serious  lesions  of  the  nerves.  These  affect  the  nerves 
themselves,  the  muscles,  and  the  skin.  The  nerves  un- 
dergo a  degeneration  ;  the  medullary  sheath  breaks  up 
into  granular  material,  which  is  absorbed,  the  axis 
cylinder  also  undergoing  a  change.  The  muscles  lose 
their  striated  character,  and  after  a  while  are  changed 
into  fatty  debris,  which  is  finally  absorbed.  Accom- 
panying these  changes,  there  is  usually  more  or  less 
multiplication  of  nuclei. 

The  skin  may  be  covered  with  an  erythematous 
eruption,  or  the  eruption  may  be  vesicular.  Herpes 
and  eczema  are  not  uncommon.  Sometimes  the  skin  is 
thickly  covered  with  minute  scales  of  epithelium,  which 
can  be  readily  brushed  off. 

Mitchell  has  described  the  glossy  skin  which  is 
found  frequently  after  nerve-lesion.  This  is  most  com- 
monly seen  in  the  fingers,  perhaps  in  the  foot.  The 
skin  has  a  peculiar  shiny  appearance,  without  wrinkles, 
without  hairs.  When  the  fingers  are  affected,  they  ta- 
per off  to  their  ends,  and  it  is  very  common  to  have  a 
severe  pain  as  an  accompaniment  of  this  condition,  cau- 
salgia.  Occasionally  ulcers  form,  mal  perf orant,  though 
this  is  comparatively  rare.  The  nails  become  brittle, 
rough,  and  deformed.  The  hair  may  fall  out,  or  grow 
to  an  inordinate  length,  and  sometimes  loses  its  color, 
becoming  gray  or  white. 

DiAaTTOSis.  —  The  diagnosis  between  paralysis  of 
peripheral  origin  and  of  central  origin  must  be  made  in 
large  part  from  the  other  symptoms.  Electricity  is  the 
most  valuable  agent  in  forming  the  diagnosis.  If  there 
is  the  reaction  of  degeneration,  it  is  certain  that  either 


288       DISEASES  OF  THE  PERIPHERAL  NERVES. 

the  nerves  are  diseased  or  tlie  large  cells  of  the  anterior 
cornua  of  the  spinal  cord  have  undergone  degeneration. 
If,  then,  a  disease  of  the  spinal  cord  can  be  excluded, 
the  diagnosis  is  clear. 

Multiple  neuritis  has  been  already  considered. 

Peognosis. — A  very  large  number  of  cases  of  pe- 
ripheral paralysis  recover  completely.  The  more  se- 
vere, however,  the  original  injury,  or  the  more  com- 
plete the  degeneration  of  the  nerve  caused  by  disease, 
the  slower  will  be  recovery,  and  the  more  likely  per- 
manent impairment  of  motion  will  result. 

Among  the  most  favorable  cases  are  those  which 
arise  from  simple  pressure,  from  rheumatic  disturb- 
ance, or  from  poisons  and  from  syphilis. 

Even  where  the  reaction  of  degeneration  is  found, 
recovery  is  not  to  be  despaired  of,  and  treatment  should 
be  persevered  in  for  many  months.  The  less  perfectly 
the  reaction  of  degeneration  is  established,  the  more 
favorable  is  the  indication.  When  secondary  contrac- 
tion has  set  in,  or  when  the  reaction  of  degeneration 
has  evidently  continued  for  many  months,  the  progno- 
sis is  very  unfavorable. 

Treatment.  —  The  treatment  of  these  paralyses 
must  be  directed  first,  of  course,  to  a  removal  of  the 
cause  if  possible.  Injuries  and  other  diseases  should 
receive  their  appropriate  treatment.  If  tumors  can  be 
removed  without  destruction  of  a  nerve,  in  course  of 
time  the  paralysis  will  disappear. 

In  cases  of  exhaustion,  rest  is  sometimes  sufficient 
for  recovery  ;  if  not,  then  the  same  means  should  be 
used  as  in  other  cases  of  protracted  paralysis.  In  cases 
of  syphilis,  the  anti-syphilitic  treatment  should  be  vig- 
orously pursued.  Warmth  to  the  limb  is  quite  imx)or- 
tant.  Electricity  is  of  more  value  than  any  other  agent. 
The  galvanic  current  should  be  used,  the  current  being 
slowly  interrupted,  the  negative  pole  being  placed  over 
the  motor  points  of  the  affected  muscle.  In  cases  of 
paralysis  due  to  pressure  or  exhaustion,  or  after  acute 


PERIPHERAL  PARALYSIS.  289 

diseases,  tliis  is  usually  sufficient.  In  cases  of  rheu- 
matic paralysis  it  may  be  well,  also,  to  paint  over  the 
affected  nerve  with  tincture  of  iodine.  Where,  how- 
ever, there  is  reason  to  suspect  that  a  neuritis  has  oc- 
curred, small  blisters  placed  over  the  nerve,  as  described 
under  neuritis,  will  hasten  the  cure. 

Internal  remedies  are  of  little  or  no  value  so  far  as 
the  paralysis  is  concerned  ;  they  may  be  required,  how- 
ever, for  the  general  health  and  condition  of  the  pa- 
tient. 

SPECLiL  rOEMS   OF  PARALYSIS. 

The  nerves  which  move  the  eye  are  frequently  sub- 
jected to  pressure  and  injury  from  syphilitic  disease  of 
surrounding  parts,  especially  of  the  membranes  of  the 
brain  ;  and,  as  these  nerves  pass  through  the  bony  ca- 
nals at  the  base  of  the  skull,  they  are  easily  com- 
pressed, not  only  by  such  growths,  but  also  by  the  in- 
fluence of  cold,  producing  a  congestion  and  swelling 
and  inflammation  of  the  surrounding  tissues. 

When  these  nerves  are  paralyzed,  vision  will  be  more 
or  less  interfered  with.  If  the  third  nerve  is  affected, 
the  drooping  of  the  eyelid  and  loss  of  power  of  ac- 
commodation may  disturb  vision,  even  when  the  mo- 
tions of  the  eyeball  seem  to  be  perfect.  W^hen  the 
muscles  of  the  eyeball  are  paralyzed,  in  consequence  of 
injury  to  their  nerves,  there  is  more  or  less  immobility 
of  the  eye,  and  hence  strabismus  results.  A  very  care- 
ful description  of  the  various  forms  of  strabismus  may 
be  found  in  Ziemssen's  "Cyclopaedia,"  vol.  xi,  or  in 
Ross's  work  on  the  "  Diseases  of  the  I^ervous  System," 
or  in  books  on  diseases  of  the  eye. 

The  seventh  nerve,  the  facial  nerve,  is  perhaps  more 
frequently  affected  by  the  so-called  rheumatic  pa- 
ralysis than  any  other  nerve  of  the  body.  Passing 
through  a  bony  canal  near  the  ear,  being  very  super- 
ficial where  it  leaves  that  canal,  it  is  specially  exposed 
to  such  a  disturbance.  Draughts  of  air  while  riding, 
or  sitting  at  an  open  window,  or  other  exposure  of  one 

19 


290       DISEASES  OF  THE  PERIPHERAL  NERVES. 

side  of  the  face,  may  be  sufficient  to  give  rise  to  this 
paralysis. 

As  the  seventh  nerve  passes  through  the  temporal 
bone,  separated  by  a  very  thin  lamina  of  bone  from  the 
tympanic  cavity  of  the  ear,  it  is  very  liable  to  disturb- 
ance in  cases  of  inflammation  of  the  middle  ear.  New 
growths  in  the  ear  may  also,  by  pressure,  cause  absorp- 
tion of  the  thin  layer  of  bone,  and  press  upon  the 
nerve.  Blows  upon  the  side  of  the  head,  and  other  in- 
juries, may  likewise  result  in  facial  paralysis. 

As  the  facial  nerve  is  at  its  origin  exclusively  a 
nerve  of  motion,  when  it  is  paralyzed  the  symptoms 
are  chiefly  those  of  loss  of  motion  ;  in  its  course,  how- 
ever, through  the  Fallopian  canal  it  receives  a  few 
branches — one  of  special  sense,  of  taste,  and  another, 
near  its  exit  from  that  canal,  of  common  sensation. 
The  auricular  branch,  from  the  vagus,  passes  through 
the  temporal  bone,  quite  near  the  facial  nerve,  and 
gives  a  small  branch  to  it.  Probably  in  consequence 
of  the  proximity  of  this  nerve,  many  times  the  first 
symptom  of  facial  paralysis  is  pain  in  the  region  of  the 
ear,  and  generally  there  is  more  or  less  discomfort,  if 
not  actual  pain,  during  the  early  part  of  the  disease. 

The  most  common  symptom  in  paralysis  of  the 
seventh  nerve  is  loss  of  power  in  all  the  muscles  on 
that  side  of  the  face.  Not  only  those  of  the  lower  part 
of  the  face,  which  are  affected  in  cases  of  cerebral  dis- 
ease, but  also  the  muscles  of  the  forehead,  and  the  or- 
bicular muscles  of  the  eyelids,  are  paralyzed  ;  hence  the 
eye  remains  partly  open,  and  even  in  sleep  is  not  en- 
tirely closed,  although  the  eyeball  may  turn  upward, 
so  that  the  pupil  is  covered.  The  lids  are  not  closely 
applied  to  the  eyeball ;  hence,  the  tears  do  not  find  a 
ready  entrance  to  the  nasal  duct,  and  the  eye  waters 
continually. 

There  may  also  be  a  loss  of  taste  in  the  anterior 
part  of  the  tongue,  and  it  has  been  claimed  that  the 
secretion  of  saliva  is  less  on  that  side. 


PERIPHERAL  PARALYSIS.  291 

Sometimes  the  velum  palati  is  affected  and  hangs 
down  loosely  on  the  paralyzed  side,  and,  when  the  mus- 
cles are  brought  into  action  in  speaking,  the  action  be^ 
ing  much  greater  on  the  sound  side,  the  palate  is  drawn 
over  toward  that  side.  Sometimes  the  uvula  has  an  ob- 
lique direction.  Sense  of  hearing  may  be  somewhat 
more  acute  on  the  paralyzed  than  on  the  opposite  side. 

The  tongue  is  protruded  straight ;  but  sometimes, 
owing  to  the  uneven  position  of  the  lips,  the  tongue 
appears  to  deviate.  Careful  observation  of  its  position 
relative  to  the  teeth  will  prevent  any  error. 

The  reaction  of  degeneration  is  found  in  the  mus- 
cles. The  electrical  reaction  is  of  value  as  aiding  in  a 
formation  of  prognosis.  In  very  mild  cases  the  reac- 
tion of  degeneration  may  not  set  in ;  in  cases  of  me- 
dium severity,  the  extreme  form  of  the  reaction  of  de- 
generation will  not  appear. 

It  is  possible,  from  certain  peculiarities  of  the  pa- 
ralysis, to  diagnosticate  very  closely  the  seat  of  the  le- 
sion. Erb  has  briefly  stated  the  points  of  diagnosis, 
which  may  be  summarized  as  follows  : 

1.  If  there  is  complete  paralysis  of  all  the  branches, 
if  there  is  no  disturbance  of  taste  or  hearing,  and  no 
paralysis  of  the  palate,  and  if  the  electrical  reaction  is 
normal,  the  trunk  of  the  facial  is  affected  external  to 
the  Fallopian  canal. 

2.  Paralysis  of  all  the  external  branches,  with  reac- 
tion of  degeneration  and  absence  of  disturbance  of 
taste,  shows  that  the  cause  of  the  paralysis  is  within 
the  canal  and  below  the  origin  of  the  chorda  tympani. 

3.  With  the  same  symptoms  and  disturbance  of 
taste,  the  cause  is  between  the  origin  of  the  chorda 
tympani  and  the  ganglion  geniculatum.  If  the  hear- 
ing is  abnormally  acute,  the  lesion  must  be  above  the 
origin  of  the  stapedius  nerve  ;  otherwise  below  it. 

4.  If,  with  the  above  symptoms,  there  is  paralysis 
of  the  velum  palati,  the  lesion  is  in  the  vicinity  of  the 
ganglion  geniculatum. 


292       DISEASES  OF  THE  PEBIPEERAL  NEBVES. 

5.  If  all  the  above  symptoms,  except  disturbance 
of  taste,  are  present,  and  especially  if  there  is  also  dull- 
ness of  hearing  and  tinnitus,  the  lesion  is  at  the  base  of 
the  skull ;  and  this  is  rendered  still  more  certain  if 
other  cranial  nerves  are  affected. 

6.  Erb  states  that  if  the  same  symptoms  as  in  !N"o. 
5  are  present,  except  simple  diminution  of  the  electri- 
cal instability  instead  of  reaction  of  degeneration,  and 
especially  if  unusual  or  crossed  reflex  action  be  pres- 
ent, lesion  of  the  facial  nucleus  may  be  diagnosticated ; 
and  this  is  yet  more  certain  if  other  cerebral  nerves 
having  their  origin  in  this  part  are  also  paralyzed. 

After  facial  paralysis  has  continued  for  two  or  three 
months,  it  is  not  uncommon  to  have  secondary  contrac- 
tion set  in,  which  delays  recovery.  The  face,  when  at 
rest,  may  then  have  a  more  natural  appearance  ;  but, 
when  the  mouth  is  moved,  the  difference  in  the  two 
sides  becomes  apparent.  Erb  explains  this  condition 
as  due  to  the  changes  that  occur  in  muscles  where  there 
is  the  reaction  of  degeneration. 

DiAGiTOSis.  —  The  diagnosis  of  perii:)heral  facial 
paralysis,  from  that  caused  by  central  lesion,  is  of 
much  importance,  especially  for  the  comfort  of  the 
patient. 

The  reaction  of  degeneration  is  one  of  the  most  im- 
portant aids  ;  in  cases  due  to  lesions  of  the  brain,  as  a 
rule,  only  the  lower  branches  of  the  nerve  are  affected, 
those  that  go  to  the  eye  and  forehead  acting  normally. 
In  cases  of  tumor  or  other  disease  within  the  skull, 
pressing  upon  the  nerve  just  before  it  leaves  the  skull, 
there  are  general  symptoms  of  tumor  as  well  as  those 
relating  to  other  nerves,  especially  the  auditory,  which 
will  aid  materially  in  a  diagnosis. 

Paralysis  due  to  diseases  of  the  ear  must  be  diag- 
nosticated by  the  symptoms  which  are  more  particu- 
larly referable  to  the  ear.  The  large  majority  of  cases 
are  due  to  the  action  of  cold,  so-called  rheumatic  pa- 
ralysis, and  the  history  will  not  always  aid  in  forming  a 


PERIPHERAL  PARALYSIS.  293 

diagnosis,  as  patients  very  often  are  not  aware  that  they 
have  been  exposed. 

Peogxosis. — In  the  lighter  forms  of  rheumatic  pa- 
ralysis the  majority  of  cases  get  well.  Some  of  the  se- 
verer cases  recover  without  special  treatment ;  yet,  gen- 
erally, if  there  is  no  treatment,  a  certain  amount  of 
deformity  remains  which  no  subsequent  treatment  bene- 
fits. The  best  results  can  be  obtained  by  the  early  use 
of  appropriate  measures. 

The  prognosis  in  cases  arising  from  disease  of  the 
ear  depends  entirely  upon  the  nature  of  that  disease 
and  the  amount  of  mischief  which  has  been  caused  to 
the  facial  nerve.  The  prognosis  in  cases  of  disease 
within  the  cranium  must  be  guided  by  the  nature  of 
that  disease. 

Teeatmei^t. — It  is  necessary  to  say  but  very  little 
in  regard  to  the  special  treatment  of  facial  paralysis. 
In  the  rheumatic  form,  painting  over  the  neck  just  be- 
low the  ear  and  behind  the  ear  with  tincture  of  iodine 
may  be  of  some  benefit.  Electricity,  the  galvanic  cur- 
rent by  preference,  interrupted  at  short  intervals,  is  of 
most  value.  The  internal  use  of  remedies  is  of  no  value 
except  in  syphilitic  cases. 

PARALYSIS  OF  THE  BRACHIAL  PLEXUS. 

There  is  nothing  peculiar  in  the  symptoms  found  in 
paralysis  of  the  brachial  plexus.  A  knowledge  of  the 
distribution  of  the  nerves  to  the  muscles  will  show 
what  nerves  are  specially  affected,  and  the  resulting 
paralysis  or  deformity  depends  upon  which  muscles  are 
affected. 

Among  the  most  common  causes  are  dislocation  of 
the  humerus,  the  head  of  the  bone  pressing  upon  the 
nerves  in  the  axilla ;  pressure  of  a  crutch  upon  these 
same  nerves ;  pressure  upon  the  radial  nerve  as  it 
passes  around  the  lower  part  of  the  humerus.  This  is 
most  frequently  found  in  patients  who  have  fallen 
asleep  upon  their  arm,  especially  if  the  arm  rests  upon 


294       DISEASES  OF  THE  PERIPEERAL  NERVES. 

any  hard  substance,  and  is  more  likely  to  occur  when 
the  sleep  is  very  heavy,  or  from  intoxication.  Carry- 
ing burdens  upon  the  arm,  the  hand  resting  upon  the 
hip,  may  also  be  a  cause. 

Among  infants,  paralysis  of  these  nerves  is  some- 
times found  as  the  result  of  delayed  labor ;  the  press- 
ure upon  the  nerves  in  the  neck,  especially  by  f  orceins, 
may  be  a  cause  ;  or,  if  the  arm  is  drawn  down  in  breech 
presentations,  the  nerves  may  be  injured  in  the  opera- 
tion. This  is  the  so-called  obstetric  paralysis  of  in- 
fants. 

Other  forms  of  peripheral  paralysis  require  no  spe- 
cial mention. 

PARALYSIS   AFTER   ACUTE   DISEASES. 

Many  acute  diseases  are  sometimes  accompanied 
with  or  followed  by  paralysis.  Apparently  the  nature 
of  the  lesion  which  caused  the  paralysis  is  different  in 
different  cases. 

Among  the  diseases  which  are  most  frequently  thus 
accompanied  with  local  or  more  general  paralysis  may 
be  mentioned  small-pox,  measles,  scarlatina,  typhoid 
fever,  dysentery,  sometimes  diarrhoea,  cholera,  pneu- 
monia, and  diphtheria. 

Generally,  except  in  diphtheria,  the  paralysis  oc- 
curs during  the  course  of  the  disease,  and  may  be 
found  accompanying  apparently  light  cases  as  well  as 
the  more  severe. 

Many  times  it  seems  as  though  an  unusually  high 
fever,  perhaps  of  very  short  duration,  were  the  exciting 
cause  of  the  paralysis. 

Several  times  changes  have  been  found  in  the  spinal 
cord.  This  is  especially  true  of  small-pox.  In  other 
cases  the  paralysis  seems  to  be  of  peripheral  origin. 
The  legs  are  more  frequently  attacked  than  the  arms. 

The  prognosis  in  almost  all  these  cases  is  compara- 
tively favorable  unless  the  spinal  cord  is  the  seat  of  the 
disease  ;  yet  occasionally  serious  injury  is  done  to  the 


DIPHTHERITIC  PAEALTSIS.  295 

nerves  or  nerve-centers,  and  recovery  is  imperfect,  the 
patient  remaining  more  or  less  helpless  during  the  rest 
of  life,  with  atrophy  of  the  paralyzed  muscles. 

The  treatment  is  such  as  has  been  already  indicated 
in  speaking  of  peripheral  paralysis,  or  such  as  is  re- 
quked  in  corresponding  cases  where  the  nerve-centers 
are  affected. 

DIPHTHERITIC  PARALYSIS. 

Diphtheritic  paralysis  requires  rather  more  atten- 
tion than  has  been  given  to  those  arising  from  other 
acute  diseases.  It  occurs  after  the  primary  disease  has 
ceased.  The  patient  is  thought  to  have  recovered 
health,  and  from  eight  to  thirty  days  afterward  the 
nervous  disturbance  is  first  noticed.  The  paralysis 
may  appear  after  either  severe  or  light  cases  of  diph- 
theria. When  it  occurs  soon  after  the  primary  disease, 
it  is  more  gradual  in  its  onset,  and  successive  nerve- 
regions  are  affected  one  after  the  other. 

Diphtheria  is  most  common  between  the  ages  of 
two  and  twelve.  The  paralysis  following  diphtheria  is 
most  common  between  the  ages  of  ten  and  eighteen. 
It  is  impossible  to  foretell  whether  or  not  the  patient 
will  have  paralysis  following  diphtheria. 

Symptoms. — The  temperature  often  rises  for  a  short 
time  before  the  occurrence  of  the  paralysis.  In  the  ma- 
jority of  cases  there  is  first  a  slight  change  in  the  voice, 
which  becomes  nasal.  The  velum  palati  and  the  mus- 
cles of  the  larynx  being  paralyzed,  there  is  regurgita- 
tion in  swallowing  liquids.  When  the  attempt  is  made 
to  swallow  food,  a  portion  passes  down  the  wrong  way 
into  the  larynx,  causing  choking  and  coughing. 

Sometimes  disturbance  of  sight  is  the  first  symp- 
tom, there  being  dimness  or  partial  loss  of  vision  on 
account  of  paralysis  of  the  muscles  of  accommodation. 
Strabismus  may  be  caused  by  paralysis  of  the  motor 
muscles  of  the  eyeball. 

Frequently  the  legs  lose  the  power  of  motion  ;  the 


296       DISEASES  OF  THE  PERIPHERAL  NERVES 

patient  is  unable  to  walk.  ISText  in  frequency  the  arms 
and  hands  are  affected.  Occasionally  there  is  paralysis 
of  the  diaphragm,  and  less  frequently  of  the  heart.  It 
is  rare  to  have  a  case  in  which  the  paralysis  is  general. 
Usually  one  or  two  limbs  are  most  affected,  the  others 
being  only  slightly  affected,  or  escaping  entirely,  and 
in  the  majority  of  the  cases  the  paralysis  is  limited  to 
the  velum  palati  and  the  larynx. 

The  reaction  of  degeneration  is  very  common  in 
diphtheritic  paralysis ;  indeed,  in  the  majority  of 
cases  the  loss  of  power  is  due  to  a  lesion  of  the  ante- 
rior roots  of  the  spinal  nerves.  It  is  supposed,  how- 
ever, that  the  disturbance  in  the  throat  is  due  to  a 
lesion  of  the  nerve  as  it  passes  near  the  seat  of  the 
original  disease. 

Sensation  is  only  exceptionally  disturbed.  Yery 
rarely,  instead  of  loss  of  motor  power,  severe  pain  is 
felt  in  the  course  of  certain  nerves. 

DiAGisrosis. — The  history  of  a  previous  sore  throat 
or  attack  of  diphtheria  is  sufficient  to  show  the  nature 
of  the  subsequent  nerve-lesion.  Without  such  his- 
tory it  would  be  impossible  to  recognize  the  cause  of 
the  paralysis,  though  the  nasal  voice,  the  regurgitation 
of  food,  and  the  choking  in  swallowing,  might  lead 
one  to  suspect  that  there  had  been  a  diphtheria  which 
had  been  overlooked. 

Peogistosis. — The  prospect  is  generally  favorable, 
although  occasionally  patients  die  from  an  extension 
of  the  paralysis  to  the  heart  or  muscles  of  respiration, 
and  sometimes  from  inhalation's  pneumonia,  due  to  the 
passage  of  food  into  the  bronchi.  Except  in  such  cases, 
the  patients  almost  invariably  recover  under  proper 
treatment. 

Treatment. — Where  deglutition  is  seriously  inter- 
fered with,  the  greatest  care  will  be  necessary  in  the 
treatment  of  the  patient  to  avoid  the  passage  of  food 
into  the  trachea. 

Usually  a  soft  solid  can  be  swallowed  better  than 


4  DIPETEERITIG  PARALYSIS.  297 

liquid  food  ;  but  in  many  cases  it  is  necessary  to  omit 
feeding  tlie  patient  by  the  mouth  for  a  while,  and  in 
that  case  food  should  be  given  by  enemata,  in  the  way 
which  has  already  been  described.  If  necessary,  a  tube 
may  be  passed  down  the  throat  into  the  stomach,  and 
the  patient  can  be  thus  supported  by  artificial  feeding. 

Paralysis  of  the  limbs  should  be  treated  by  keeping 
the  limbs  warm,  by  massage,  by  stimulating  bathing, 
as  with  salt-water,  warm  rather  than  cold,  and  by  the 
use  of  electricity. 

Iodide  of  iron  is  one  of  the  most  valuable  tonics  for 
such  patients,  and  cod-liver  oil,  if  it  can  be  taken,  is  of 
great  use.  Otherwise,  except  as  indicated  by  the  pa- 
tient's general  condition,  no  special  treatment  is  neces- 
sary. 


CHAPTER  XXV. 

SPASM. 

NoTHNAGEL,  Zur  Lehre  von  klonische  Krampfe.  Virch.  Arch., 
xlix,  pp.  267,  290. — Mitchell,  S.  W.,  On  Functional  Spasm.  Am. 
Jour,  of  the  Med.  Sci.,  Oct.,  1876,  p.  321. — Mills,  C.  K.,  Spasms 
of  the  Muscles  supplied  by  the  Spinal  Accessory  Nerve.  Am.  Jour, 
of  the  Med.  Sci.,  Oct.,  1877,  p.  425.— Remak,  E.,  Zur  Pathologie 
und  Therapie  localisirte  Muskelkrampf e.  Berl.  Tel.  Wochenschr. , 
May  23,  1881,  p.  289. — Jones,  C.  H.,  Clinical  Lecture  on  a  Case 
of  Spasmodic  Disorders  of  the  Lower  Limbs.  Brit.  Med.  Jour., 
July  2,  1881,  p.  41. — Robinson,  E.,  Cases  of  Telegraphists'  Cramp. 
Brit.  Med.  Jour.,  Nov.  4, 1882,  p.  880. — Sinkler,  Spinal  Accessory 
Spasm.  Med.  News,  April  19,  1884,  p.  453.— Poore,  G.  V.,  An 
Analysis  of  Seventy-five  Cases  of  Writers'  Cramp.  Med.-Chir. 
Trans.,  61,  1878,  p.  111. — Ibid.,  Writers'  Cramp.  Practitioner, 
1873. — Althaus,  J.,  On  Scriveners'  Palsy.  London,  1870. — ViGOU- 
ROUX,  R.,  Du  traitement  de  la  crampe  des  ecrivains  par  la  me- 
thode  de  Wolff.  Le  prog,  med.,  x,  1882,  p.  37.— Thomsen,  J., 
Tonische  Krampfe  in  willkiirlich  beweglichen  Muskeln  in  Folge 
von  ererbter  psychischer  Disposition.  Arch.  f.  Psych.,  vi,  1876, 
p.  702.  —  Ballet  et  Marie,  Spasme  musculaire  au  debut  des 
mouvements  volontaires.  Arch,  denevrol.,  Jan.,  1883,  p.  1. — Rin- 
ger, Sydney,  On  the  Nervous  or  Muscular  Origin  of  Certain 
Spastic  Conditions  of  the  Voluntary  Muscles.  Lancet,  Nov.  1, 
1884,  p.  767  et  seq. 

The  convulsive  actions  included  under  the  name 
spasm  are  of  several  varieties. 

Tremor  is  a  very  fine  spasm  of  the  muscles,  vrhich 
produces  a  trembling  of  the  limbs,  sometimes  scarcely 
perceptible.  It  is  rather  a  symptom  of  several  morbid 
conditions  than  a  disease  of  itself. 

Tonic  spasm  is  a  name  given  to  the  spasm  v^hen  a 
muscle  is  contracted  continuously  without  relaxation. 


SPASM.  299 

Tliis,  also,  is  rather  a  symptom  tlian  a  disease,  being 
found  more  especially  in  tetanus  and  spinal  meningitis. 
It  is  sometimes  difficult  to  recognize  the  difference  be- 
tween a  tonic  spasm  and  what  is  called  contracture  of 
the  muscles  ;  in  fact,  the  latter  may  be  looked  upon  in 
its  earlier  stages  as  simple  tonic  spasm,  but  later  there 
is  usually  a  change  of  structure  in  the  muscles,  and, 
the  contracture  becoming  permanent  and  depending  in 
large  measure  upon  this  change  of  structure,  can  no 
longer  be  called  a  tonic  spasm. 

Clonic  spasm  is  a  name  given  to  the  convulsions 
which  are  attended  with  a  rapid  contraction  and  relax- 
ation of  muscles.  When  these  clonic  spasms  are  ex- 
treme, and  large  groups  of  muscles  are  attacked,  the 
name  convulsions,  or  eclampsia,  is  used  rather  than 
clonic  spasm,  the  latter  nanae  being  reserved  for  the 
less  severe  and  less  extensive  convulsions. 

In  the  following  descriptions,  clonic  spasms  will  be 
chiefly  considered. 

These  are  generally  reflex  in  their  origin,  depending 
upon  the  irritation  of  some  sensitive  peripheral  nerve, 
possibly  far  from  the  seat  of  the  spasm.  They  many 
times,  also,  depend  upon  lesion  of  the  central  nervous 
system,  in  which  case  they  are  simply  symptoms  of 
the  disease  which  gives  rise  to  them.  All  such  cases 
of  spasm  of  central  origin  have  been  considered  under 
diseases  of  the  nerve-centers. 

It  is  not  necessary  to  mention  in  detail  spasms  of  all 
the  various  nerves.  A  few  have  such  peculiar  charac- 
teristics, and  occur  so  frequently,  as  to  be  deserving  of 
a  separate  mention. 

SPASM  or  THE  FACIAL  NERVE. 

Irritation  of  the  facial  nerve  in  its  course  through 
the  temporal  bone,  or  at  the  base  of  the  skull,  may  give 
rise  to  a  spasm  of  the  muscles  supplied  by  it.  Slight 
spasm  of  the  muscles  of  the  face  is  sometimes  seen 
after  facial  paralysis.    Irritation  of  the  fifth  nerve  may, 


300       DISEASES  OF  THE  PERIPHERAL  NERVES. 

by  reflex  means,  also  produce  spasm  of  the  facial  mus- 
cles. Yery  severe  convulsive  action  of  these  muscles 
may  accompany  the  pain  in  severe  cases  of  trifacial 
neuralgia ;  or,  without  pain,  decayed  teeth,  inflamma- 
tion of  the  conjunctivae,  abscesses  about  the  face  or  in 
the  cavity  of  the  mouth,  the  influence  of  very  bright 
light  upon  the  eyes,  as  from  the  molten  metal  in  a 
blast-furnace,  may  be  causes. 

An  irritation  of  distant  organs,  as  the  intestinal  tract, 
or  the  uterus,  seems  sometimes  to  be  the  starting-point 
of  facial  spasm. 

This  spasm  is  generally  unilateral.  All  the  mus- 
cles of  one  side  of  the  face  may  be  thrown  into  violent 
convulsions,  producing  the  most  ludicrous  grimaces, 
lasting  for  a  few  seconds,  relaxation  being  followed 
soon  by  another  attack. 

The  series  of  attacks  may  continue  for  several  sec- 
onds or  minutes,  when  there  is  a  period  of  rest  until 
the  next  attack  occurs.  Or,  instead  of  general  spasm, 
one  or  a  few  muscles  may  be  affected.  There  may  be 
slight  twitching  about  the  mouth  or  face.  It  may  seem 
almost  as  if  the  patient  had  simply  acquired  a  habit  of 
which  he  might  be  readily  broken.  These  spasms,  how- 
ever, are  very  frequently  involuntary  and  entirely  be- 
yond the  control  of  the  will. 

Sometimes  the  orbicularis  palpebrarum  is  exclu- 
sively affected ;  then  the  patient  closes  the  eye  violent- 
ly, or  simply  winks  rapidly.  Occasionally  the  muscles 
of  the  forehead  are  also  implicated. 

Blepharospasm  is  a  tonic  spasm  of  the  eyelids,  the 
contraction  of  the  orbicular  muscle  persisting  some- 
times for  many  minutes,  or  even  hours.  A  bright  light, 
an  attempt  to  use  the  eyes  for  near  vision,  especially 
where  great  care  is  necessary  in  seeing  small  objects,  as 
fine  print,  is  sufficient  to  bring  on  an  attack  in  those 
who  are  subject  to  this  form  of  spasm.  Sometimes  a 
simple  mental  emotion  will  cause  an  attack. 

Pressure  upon  certain  parts  of  the  face  may  have 


TORTICOLLIS.  301 

tlie  effect  of  relaxing  this  spasm,  and  occasionally  such 
pressure  will  cause  other  facial  spasms  to  cease.  These 
points  correspond  to  the  painful  points  in  facial  neu- 
ralgia ;  or  such  points  may  be  found  within  the  cavity 
of  the  mouth,  or  over  the  back  of  the  neck,  or  even  in 
regions  supplied  by  the  brachial  plexus  of  nerves.  Pa- 
tients frequently  learn  where  these  points  are,  and  are 
able  to  cut  short  the  spasm  themselves. 

TORTICOLLIS,  OR  WRY-NECK. 

Slight  attacks  of  wry-neck  may  follow  exposure  to 
cold,  and  is  spoken  of  as  stiff-neck.  This  may  also  be 
the  cause  of  more  severe  attacks  ;  it  is  said  to  arise  also 
by  reflex  influence  from  irritation  of  the  abdominal 
and  pelvic  viscera;  in  very  many  cases  the  cause  is 
unknown. 

Symptoms. — The  muscles  affected  in  this  form  of 
spasm  are  those  supplied  by  the  spinal  accessory  nerve, 
the  trapezius,  and  the  sterno-cleido-mastoid.  When 
the  latter  is  contracted,  the  head  is  drawn  over  so  that 
the  occiput  approaches  the  shoulder  of  the  affected 
side ;  the  chin  is  turned  toward  the  opposite  side,  and 
slightly  upward.  When  the  trapezius  is  affected,  the 
head  is  drawn  backward,  and  inclined  toward  the 
affected  side.  There  is  no  rotation.  Sometimes  the 
shoulder  is  raised.  The  spasm  usually  begins  so  qui- 
etly and  mildly  that  the  motion  at  first  is  not  notice- 
able. Soon  the  action  of  the  muscle  becomes  stronger, 
and  then  the  head  is  turned  and  jerked  in  a  very  dis- 
tressing manner. 

The  spasms  occur  in  separate  paroxysms,  lasting  for 
a  few  seconds  or  minutes,  frequently  repeated,  at  times, 
with  long  intervals  of  rest.  Sometimes  other  muscles 
are  also  affected  besides  those  above  mentioned. 

Patients  learn  to  support  the  head  by  their  hands, 
and  forcibly  to  restrain  the  unpleasant  action  of  the 
muscles.  In  violent  cases,  however,  this  manoeuvre  is 
only  partially  successful. 


302       DISEASES  OF  TEE  PEBIPEERAL  NERVES 

Sleep  may  be  interfered  with.  It  may  be  difficult 
for  the  patient  to  take  food.  The  mental  influence  of 
the  affliction  is  such  as  to  cause  depression  of  spirits 
and  diminish  the  appetite ;  the  patients  may  become 
thin  and  emaciated  in  consequence.  Slight  cases,  how- 
ever, have  no  effect  upon  the  general  health. 

These  muscles  are  occasionally  affected  with  tonic 
spasm,  in  which  case  the  head  is  firmly  fixed  in  the  po- 
sitions above  mentioned. 

Diagnosis  and  Prognosis. — The  diagnosis  of  these 
spasms  is  not  difficult.  The  principal  mistake  would 
be,  in  cases  of  tonic  spasm,  to  consider  that  the  antago- 
nistic muscles  were  paralyzed.  Spasm  of  other  mus- 
cles of  the  neck  may  be  mistaken  for  those  already 
mentioned.  When  the  splenius  capitis  is  affected,  the 
head  is  drawn  backward  and  toward  the  affected  side, 
the  chin  is  somewhat  depressed  and  directed  toward 
the  side  of  the  spasm,  and  a  hard  ridge  can  be  felt 
where  the  splenius  appears  beneath  the  anterior  border 
of  the  trapezius.  Spasm  of  the  obliquus  capitis  infe- 
rior turns  the  head  around  its  vertical  axis  without  ele- 
vation of  the  chin  or  depression  of  the  mastoid  process. 
Spasm  of  the  deep  muscles  of  the  neck  draws  the  head 
strongly  backward  if  bilateral,  or  toward  the  affected 
side  when  unilateral.    (Ross.) 

In  both  facial  spasm  and  torticollis  the  prognosis  is 
very  unfavorable.     Very  few  cases  recover. 

Treatment  seems  to  be  of  very  little  value.  '  In 
some  cases  electricity  is  successful.  The  galvanic  cur- 
rent should  be  applied  to  the  affected  muscles,  and  the 
faradic  current  to  their  antagonists. 

Apparatus  to  produce  permanent  compression  over 
the  points  of  arrest  has  been  tried,  in  some  cases  with 
success. 

Stretching  of  the  spinal  accessory,  as  it  runs  along 
the  posterior  edge  of  the  sterno-mastoid,  has  been  em- 
ployed with  success  in  curing  the  spasm  of  torticollis. 
Division  of  muscles,  or  their  tendons,  has  been  em- 


SPASM.  303 

ployed  in  some  cases  with  advantage,  especially  in  the 
tonic  form  of  spasm.  Counter-irritation  over  the  nerves 
supplying  the  affected  muscles,  by  means  of  blisters  or 
the  actual  cautery,  may  be  of  value. 

Of  internal  remedies,  the  most  successful  have  been 
phosphate  of  zinc,  sulphate  of  zinc,  bromide  of  potas- 
sium, arsenic,  and  especially  subcutaneous  injection  of 
atropia. 

Spasm  op  the  Diapheagm,  if  tonic,  may  be  the 
cause  of  death,  and  is  always  a  serious  affection.  It 
rarely  occurs  independently  of  other  disease. 

Clonic  Spasm  of  the  Diaphragm,  or  Hiccough, 
may  be  a  light  affection,  with  which  every  one  is  fa- 
miliar, or  it  may  be  a  serious  and  obstinate  symptom 
of  disease  of  the  viscera  or  of  the  nervous  system. 

It  is  frequently  associated  with  gastric,  intestinal, 
and  hepatic  diseases,  and  in  many  cases  is  a  symptom 
of  bad  omen,  indicating  the  approaching  fatal  termi- 
nation. When  existing  independently  of  serious  dis- 
ease, it  is  often  obstinate,  resisting  treatment. 

The  galvanic  current  applied  along  the  course  of  the 
phrenic  nerve,  or,  locally,  over  the  insertions  of  the 
diaphragm  ;  the  faradic  current  applied  to  the  epigas- 
trium ;  hot  applications  over  the  epigastrium — may  be 
of  benefit.  Subcutaneous  injections  of  atropia  are 
especially  useful,  and  those  of  morphia  are  of  benefit. 

Thomsen's  Disease.— a  form  of  spasm  has  lately 
been  described  which  is  of  more  interest  as  a  curiosity 
than  practically  as  a  disease.  It  consists  of  a  stiffness 
and  rigidity  of  the  limbs,  especially  the  legs,  appear- 
ing only  when  an  attempt  is  made  to  change  the  posi- 
tion, as  in  rising  from  a  sitting  posture,  or  commencing 
to  walk  after  standing  still.  When  the  patient  wishes 
to  take  a  step,  the  leg  is  raised  slowly,  and  with  evident 
exertion,  to  an  angle  of  about  120°.  Standing  very  un- 
steadily on  the  other,  the  patient  sets  this  down  in 
nearly  the  same  angle.    If  he  then  tries  to  raise  the 


304       DISEASES  OF  THE  PERIPHERAL  NERVES. 

other  leg,  lie  will  fall,  generally  on  tlie  knee,  rarely 
backward ;  or,  if  lie  does  not  fall,  lie  will  walk  un- 
steadily, the  hips  and  knees  bent  at  an  angle  of  120°, 
and  remaining  flexed  while  walking.  After  a  few  steps 
the  gait  improves,  and  soon  the  patient  can  walk  natu- 
rally. Passive  motion  meets  with  resistance  which  is 
more  marked  the  more  rapid  the  motion.  The  arms 
and  hands,  or  even  face,  are  sometimes  affected,  and 
there  is  a  similar  difficulty  in  executing  any  movement 
as  is  found  in  the  legs. 

The  affected  muscles  are  unnaturally  large  and  hy- 
pertrophied  ;  there  is  no  increase  of  fat ;  no  reaction  of 
degeneration,  though  the  electrical  reaction  may  be  less 
than  normal.     There  is,  as  a  rule,  no  pain,  no  cramp. 

The  disease  usually  commences  very  early  in  life, 
perhaps  is  congenital,  and  in  Thomsen's  case  seemed  to 
be  a  family  trait. 

Several  authors  locate  the  affection  in  the  muscles. 

PROFESSIONAL  CRAMP. 

Under  this  term  may  be  included  the  difficulty  which 
is  found  by  writers  and  pianists,  telegraphers,  and  oth- 
er persons  in  performing  the  various  acts  required  by 
their  profession,  in  consequence  of  spasm  or  weakness 
of  the  muscles  engaged. 

Etiology. — The  cause  of  this  affection  is  usually 
an  excessive  use  of  the  hands  and  fingers,  long  con- 
tinued, in  persons  of  a  neurotic  temperament,  or  who 
have  been  weakened  by  previous  disease  or  debility. 
Occasionally  injuries,  sprains,  blows  upon  the  hand  or 
arm,  and  exposure  to  cold,  act  as  causes. 

Symptoms. — At  first  the  difficulty  experienced  is 
very  slight,  consisting  simply  in  a  little  awkwardness 
of  motion  or  stiffness  of  the  fingers  ;  sometimes  a  mere 
unpleasant  sensation,  hardly  sufficient  to  be.  called  pain, 
indicates  the  approach  of  the  trouble.  The  arm  and 
hand  become  more  easily  and  quickly  tired.  Gradu- 
ally these  symptoms  become  more  marked ;  the  hand- 


PROFESSIONAL   CRAMP.  305 

writing  becomes  decidedly  poor  ;  spasms  appear  in  dif- 
ferent muscles,  and  sometimes  tlie  thumb  and  fingers 
are  so  strongly  flexed  that  the  pen  is  pressed  against 
the  paper  and  broken  ;  at  another  time  the  extensor 
muscles  are  affected,  and  the  fingers  open,  allowing  the 
pen  to  drop. 

There  is  rarely  decided  pain,  but  a  sense  of  weari- 
ness and  exhaustion.  Sometimes,  however,  the  dis- 
comfort is  very  great,  and  extends  up  the  arm  as  high 
as  the  shoulder.  Occasionally  pain  is  felt  along  the 
course  of  the  nerve-trunks. 

When  the  disease  is  well  advanced,  the  patient  can 
write  at  most  only  one  or  two  words — perhaps  can  not 
even  sign  his  name. 

The  arm  and  hand  can  be  used  for  the  ordinary  pur- 
poses in  life  ;  even  laborious  manual  work  can  be  per- 
formed without  difficulty ;  but,  as  soon  as  the  patient 
undertakes  to  employ  the  fingers  for  any  delicate  opera- 
tion, as  writing,  playing  the  piano,  or  sewing  or  knit- 
ting, the  symptoms  immediately  reappear. 

The  electrical  reaction  of  the  muscles  is  increased  in 
the  early  stages  of  the  disease,  and  it  is  only  after  a 
long  time  that  any  diminution  of  the  reaction  can  be 
recognized. 

Persons  affected  with  this  disease  may  learn  to  write 
with  the  left  hand  :  but  in  so  doing  should  be  careful 
not  to  overtax  that  hand  ;  if  they  do,  the  same  symp- 
toms may  appear  on  the  left  side ;  if  careful,  they  may 
be  able  to  use  the  left  hand  without  difficulty. 

Views  differ  somewhat  as  to  the  nature  of  this  af- 
fection. Althaus  looks  upon  it  as  due  to  fatigue  and 
functional  irritability  of  the  co-ordinative  centers  in  the 
upper  portion  of  the  spinal  axis.  Rossis  inclined  to 
look  upon  the  main  lesion  as  situated  either  in  the  gan- 
glion-cells of  the  spinal  cord,  or  the  nerves  when  the 
electrical  reactions  are  diminished ;  in  the  cortex  or 
conducting-path  above  the  spinal  level  when  the  elec- 
trical reactions  are  increased.     Others  consider  that  the 

20 


306       DISEASES  OF  THE  PERIPHERAL  NERVES. 

seat  of  the  disease  is  in  the  muscles  or  the  terminal 
nerve-apparatus. 

The  diagnosis  presents  no  special  difficulties.  The 
prognosis  is  far  from  favorable  except  in  very  recent 
cases. 

Treatment. — Entire  rest  from  the  cause  of  the  dis- 
ease is  absolutely  necessary  for  recovery.  This  rest 
must  continue  for  many  months — six  at  least. 

The  galvanic  current  frequently  gives  good  results. 
It  is  applied  in  various  w^ays  by  different  observers. 
One  pole  should  be  placed  on  the  neck  over  the  spinal 
column,  and  the  other  applied  over  the  affected  mus- 
cles and  nerves  of  the  arm. 

Erb  recommends  the  application  of  the  galvanic  cur- 
rent to  the  head  (transversely,  longitudinally,  oblique- 
ly) ;  also  to  the  cervical  sympathetic. 

Showering  the  arm  with  hot  or  cold  water  some- 
times gives  relief. 

Wolff  has  obtained  excellent  results  by  the  combi- 
nation of  gymnastics  and  massage.  He  uses  both  act- 
ive and  passive  motion,  exercising  the  affected  mus- 
cles until  they  are  fatigued.  The  massage  is  applied  to 
the  fingers,  hand,  wrist,  and  arm.  He  uses  percussion 
with  the  ulnar  border  of  the  hand  over  the  affected 
muscles.  His  method  has  attracted  much  attention, 
and  several  articles  have  appeared  in  recent  medical 
journals  describing  the  process. 


CHAPTER  XXYI. 

DISEASES   OF   THE   SYMPATHETIC. 

Wright,  H,  G-.,  Headaclies  :  their  Caiises  and  their  Cure. 
London,  1865. — Smith,  A.  A.,  The  Therapeutics  of  Headache. 
Med.  Record,  Aug.  5,  1876,  p.  503.— Woakes,  E.,  The  etiology 
and  Treatment  of  Occipital  Headache.  Practitioner,  April,  1878, 
p.  263. — ^Warner,  F.,  Eecurrent  Headache  in  Children.  Brit. 
Med.  Jour.,  Dec,  6,  1879,  p.  889  ;  Brain,  Oct.,  1880,  p.  309.— 
Day,  W.  H.,  Headaches  :  their  Natiu^e,  Causes,  and  Treatment. 
Philadelphia,  1883. 

LiVEiNG,  E.,  On  Migraine.  London,  1873. — Allbutt,  On  Mi- 
graine. Practitioner,  x,  1873,  p.  35 — Seguin,  E.  C,  A  Contribu- 
tion to  the  Therapeutics  of  Migraine.  N.  Y.  Med.  Bee,  Dec.  8, 
1877. — Spender,  J.  E.,  The  Treatment  of  Migraine.  Lancet,  June 
14,  1884,  p.  1144.— Hughes,  C.  H.,  Migraine.  Alienist  and  Neu- 
rologist, April,  1884,  p.  277. — Brunton,  T.  L.,  On  the  Pathology 
and  Treatment  of  some  Forms  of  Headache.  St.  Barthol.  Hosp. 
Rep.,  1883,  p.  329.— Jewell,  J.  S.,  The  Nature  and  Treatment  of 
Headaches.  Jour,  of  Nervous  and  Ment.  Diseases,  Jan. -April, 
1881. 

CEPHALALGIA.— HEADACHE.  • 

It  is  not  necessary  to  consider  headaches  occurring 
as  one  of  many  symptoms  in  various  constitutional  and 
inflammatory  diseases,  nor  as  an  attendant  upon  or- 
ganic cerebral  diseases.  Even  when  not  thus  associ- 
ated, it  is  frequently  only  one  of  several  symptoms, 
but  the  one  which  gives  most  distress,  and  requiring 
relief. 

Whatever  seriously  lowers  the  tone  of  the  nervous 
system  or  the  general  health  may  be  an  efficient  cause. 
^Neurasthenic  patients  usually  suffer  from  some  form  of 
headache,  most  frequently  of  a  dull  or  heavy  kind, 
which  is  almost  continuous. 


308  DISEASES  OF  THE  SYMPATHETIG. 

Defective  sanitary  conditions,  bad  drainage,  or  poor 
ventilation,  may  cause  the  disturbance  ;  frequently  a 
inorning  headache  may  be  traced  to  sleeping  in  an  illy- 
ventilated  room. 

Anaemia  and  hypersemia  of  the  brain  are  said  to 
cause  headache.  I  doubt  whether  the  variety  of  pain 
will  help  to  distinguish  between  these  two  conditions  : 
the  diagnosis  must  be  made  from  other  symptoms  or 
conditions.  It  is  to  be  kept  in  mind  that  an  anaemic 
patient  may  have  a  sudden  flow  of  blood  to  the  head, 
giving  rise  to  headache  of  the  congestive  variety. 

Alcohol,  tobacco,  various  deleterious  gases,  as  sul- 
phureted  hydrogen,  carbonic  oxide,  or  the  gas  used  for 
lighting,  may  cause  headache ;  chronic  lead-poisoning 
is  another  cause. 

Headache  is  sometimes  the  only  symptom  of  tertiary 
syphilis  ;  it  is  frequent  in  Bright's  disease,  and  may  be 
the  first  sign  of  trouble.  There  is  also,  apparently, 
a  connection  between  headache  and  rheumatism  and 
gout. 

A  very  large  class  of  cases  are  reflex  in  origin,  de- 
pending upon  disease  or  derangement  in  distant  or- 
gans ;  the  digestive  and  urino-genital  organs  are  most 
frequently  the  seat  of  such  disturbance. 

Differences  in  the  refractive  power  of  the  eyes  may 
be  the  exciting  cause  of  headache,  and  in  every  doubt- 
ful case  an  oculist  should  examine  the  eyes. 

A  careful  examination  of  all  the  possible  derange- 
ments is  necessary  to  form  a  correct  diagnosis  ;  but  with 
care  there  is  usually  not  much  trouble  in  arriving  at  a 
reasonable  conclusion :  in  some  cases,  however,  it  will 
not  be  possible  to  discover  the  cause  or  nature  of  the 
affection. 

Headache  is  rare  in  early  childhood,  and,  when  pres- 
ent, may  be  of  serious  import ;  it  ought  to  lead  to  a 
watchful  care  lest  it  should  be  the  forerunner  of  some 
serious  disease.  About  the  period  of  second  dentition, 
and  until  puberty,  headache  may  be  more  common. 


HEADACHE.  309 

and  is  sometimes  severe  and  continuous,  witli  remis- 
sions, but  few  intermissions.  It  is  not  then  of  a  sharp, 
piercing  character,  but  rather  heavy  and  dull,  increased 
by  mental  exertion  and  confinement. 

In  old  age  it  is  not  common,  and  is  of  more  impor- 
tance than  in  middle  life. 

Treatment. — It  may  be  necessary  to  change  the 
patient's  mode  of  life  or  residence.  If  there  is  any 
unfavorable  influence  about  the  house,  it  should  be 
remedied,  or,  if  that  is  not  possible,  the  patient  should 
change  his  residence. 

Too  severe  mental  application,  whether  in  study  or 
in  business,  must  be  moderated,  and  this  is  not  always 
easy  to  accomplish.  Sedentary  habits  must  be  broken 
in  upon,  exercise  out  of  doors  must  be  insisted  upon, 
and  late  hours,  whether  for  business  or  amusement, 
must  give  place  to  early  retiring.  High  heels  and  tight 
lacing,  and  insufficient  clothing,  need  to  be  looked 
after,  even  if  the  contest  with  what  is  thought  fashion- 
able seems  well-nigh  hopeless. 

The  diet  should  be  regulated  ;  the  high  and  gener- 
ous liver  may  expect  to  suffer  until  he  can  reduce  his 
diet.  An  occasional  saline  cathartic  may  give  tempo- 
rary relief ;  or,  if  there  is  a  gouty  tendency,  colchi- 
cum  may  be  used  ;  but  more  than  that  is  needed,  and 
while  the  patient  persists  in  indulgence  not  much  will 
be  gained.  In  gouty  cases,  citrate  of  lithia,  five  grains 
or  more  three  or  four  times  a  day,  promises  well. 

Alcohol  and  tobacco  should,  of  course,  be  given  up ; 
if  there  is  any  suspicion  of  lead-poisoning,  iodide  of 
potassium  should  be  given  to  eliminate  the  poison. 

Dyspepsia,  or  other  affections  which  may  act  as 
causes,  must  be  treated  by  appropriate  means  if  pos- 
sible. 

During  the  attack,  in  cases  of  excessive  blood-sup- 
ply, counter-irritation  to  the  back  of  the  neck,  cold  to 
the  neck,  or  an  ice-bag  to  the  lower  part  of  the  spine, 
ergotin  in  three-grain  doses,  bromide  of  potassium  in 


310  DISEASES  OF  THE  STMPATEETIG. 

thirty  to  sixty  grains  ;  if  the  pain  is  severe,  wet  cups  to 
the  back  of  the  neck,  or  leeches  behind  the  ear — may 
be  tried. 

In  nervous  headaches,  or  those  caused  by  exhaus- 
tion or  overwork,  citrate  of  caffein,  two  to  five  grains, 
is  frequently  sufficient  for  its  removal;  yet  the  caffein 
sometimes  causes  nausea.  Aromatic  spirit  of  ammonia 
and  sweet  spirit  of  niter  are  excellent  remedies ;  a  tea- 
spoonful  of  each  can  be  given,  and  repeated  in  one  or 
two  hours  if  necessary.  Valerianate  of  ammonia,  spir- 
it of  lavender,  camphor,  or  asafoetida,  may  serve  when 
other  remedies  fail.  Hot  water  to  the  head  is  usually 
more  grateful  than  cold. 

Between  the  attacks,  ergotin,  in  tendency  to  a  con- 
gestive condition,  with  care  as  to  habits.  In  other 
cases,  the  various  tonics,  cod-liver  oil,  and  good  feed- 
ing. Extract  cannabis  Indica,  in  third  to  half-grain 
doses  three  times  a  day,  has  proved  very  useful,  not 
merely  in  migraine,  as  advised  by  Seguin,  but  in  more 
common  forms.  The  drug  should  be  continued  several 
weeks. 

Iodide  of  potassium  seems  to  be  useful  in  other 
cases  than  where  there  is  a  rheumatic  or  syphilitic 
taint.  Dr.  Haley  found  that  it  relieved  a  duU,  heavy 
headache  over  the  brows  accompanied  by  languor,  chil- 
liness, and  feeling  of  discomfort.  He  gave  it  in  two- 
grain  doses,  in  half  a  wine-glass  of  water,  to  be  sipped 
slowly. 

Massage  to  the  head  will  often  relieve  the  pain  in  a 
few  minutes  ;  in  chronic  cases,  the  massage  should  be 
given  for  a  long  time,  and  may  be  general. 

The  galvanic  current,  passed  from  the  forehead  to 
the  back  of  the  neck,  or  transversely,  may  be  tried,  or 
the  faradic  current  from  forehead  to  neck.  It  is  better 
to  use  the  operator's  hand  as  the  electrode  on  the  fore- 
head, the  battery-electrode  being  held  in  his  other 
hand.  The  hand  fits  the  shape  of  the  forehead  better 
than  the  common  metallic  electrodes,  and  the  operator 


SICK  EEADACEE.  311 

can  thus  judge  more  correctly  as  to  the  strength  of  the 
current,  which  needs  to  be  very  mild. 

MEGKIM.— SICK  HEADACHE.— MIGRAINE. 

Megrim,  or  sick  headache,  is  a  paroxysmal  head- 
ache, usually  limited  to  one  side,  frequently  attended 
with  nausea  and  vomiting  ;  the  intervals  between  the 
attacks  are  usually  free  of  pain. 

Etiology. — Heredity  is  even  more  evident  in  this 
than  in  many  neuroses.  Frequently  it  occurs  in  several 
successive  generations  in  the  same  family. 

Women  are  slightly  more  liable  than  men  ;  Liveing 
says  as  5  to  4,  Eulenburg  says  as  5  to  1. 

The  first  attack  occurs  most  frequently  before  ten, 
or  at  puberty.     It  rarely  begins  after  twenty-five. 

Certain  influences,  as  imprudence  in  diet,  exhaust- 
ing exertions,  excitement,  late  hours,  noise  and  confu- 
sion, will  give  rise  to  an  attack :  and  these  may  occur 
more  frequently  at  the  catamenial  period ;  but  why  it  is 
so  we  do  not  know. 

Symptoms. — As  in  other  "explosive"  neuroses,  the 
patient  is  usually  free  from  pain,  and  in  the  enjoyment 
of  good  health,  between  the  attacks.  Sometimes  the 
paroxysm  is  preceded  by  a  warning ;  perhaps  an  un- 
usual buoyancy  of  feeling  and  sense  of  exhilaration  are 
noticed  on  the  preceding  day,  and  the  patient  knows 
he  is  about  to  be  sick  because  he  feels  so  well.  Or, 
again,  an  indisposition  begins  the  day  before,  and  gives 
notice  of  the  coming  storm. 

In  almost  every  case,  pain  is  the  most  prominent 
symptom.  The  pain  is  felt  on  waking ;  usually  it  is 
mild  at  first,  but  increases  as  the  day  advances  until  it 
reaches  its  greatest  intensity.  Sometimes  the  pain  be- 
gins later  in  the  day,  and  occasionally  it  is  absent 
throughout  the  attack,  the  other  symptoms  alone  ap- 
pearing. The  pain  varies  much  in  character  and  se- 
verity in  different  attacks,  even  in  the  same  person.  It 
is  usually  unilateral,  the  side  affected  varying,  at  one 


312  DISEASES  OF  THE  SYMPATHETIC. 

time  tlie  left,  and  tlie  next  time,  perhaps,  tlie  right  side 
suffering.  Sometimes  it  is  bilateral,  though  then  one 
side  may  suffer  the  more  severely.  At  the  beginning 
of  the  attack  the  pain  is  limited  to  one  region,  gener- 
ally the  forehead  or  the  temple  ;  as  it  becomes  worse, 
it  spreads  over  the  whole  side  of  the  head.  The  pain 
continues  throughout  the  paroxysm,  six  or  eight  to 
twenty-four  hours,  rarely  longer,  though  a  sense  of 
heaviness  or  depression  may  remain  for  a  while  longer. 
There  is  general  tenderness  of  the  scalp  over  the  region 
affected,  rather  than  any  special  tender  points. 

Almost  from  the  commencement  of  the  pain  there  is 
a  loss  of  desire  for  food,  or  absolute  loathing  of  it.  As 
the  headache  continues,  this  feeling  changes  to  nausea, 
and  at  length  vomiting  sets  in.  One  severe  spell  of 
vomiting  may  close  the  attack,  and  the  pain  cease, 
drowsiness  or  sleep  following  or  not.  Grenerally,  how- 
ever, more  than  one  fit  of  retching  and  vomiting  occurs, 
and  the  prostration  is  correspondingly  severe,  as  the 
pallor,  sweating  and  weakness  show. 

The  drowsiness  or  heavy  sleep  which  sometimes 
follows  the  vomiting  may  be  in  part  the  result  of  the 
exhaustion  caused  by  the  pain  and  the  vomiting.  It 
is  not  like  the  quiet,  natural  sleep  which  sometimes 
closes  the  attack  ;  it  rather  resembles  the  stupor  follow- 
ing an  epileptic  fit. 

Other  symptoms  are  less  common  than  the  pain  and 
nausea.  Visual  disturbances  are  next  in  frequency, 
and,  when  present,  generally  appear  before  the  pain. 
They  consist  in  partial  or  total  loss  of  sight,  and  in  va- 
rious luminous  appearances,  of  greater  or  less  brilliancy, 
and  sometimes  colored.  The  loss  of  vision  is  sometimes 
central  and  sometimes  lateral ;  there  may  be  true  lat- 
eral hemianopsia.  The  luminous  phenomena  may  con- 
sist simply  in  the  perception  of  a  bright  light,  without 
definite  form,  or  there  may  be  zigzag  lines  of  light, 
sometimes  colored,  resembling  fortifications.  A  small 
point  of  light  is  first  seen,  which  gradually  expands, 


SICK  EEADACHE.  313 

increasing  in  size,  assuming  tlie  above  zigzag  form,  un- 
til it  extends  beyond  the  field  of  vision  and  disappears. 
Meanwhile,  a  new  spot  appears,  and  goes  through  the 
same  changes ;  the  lines  of  light  have  tremulous  mo- 
tion. 

Disturbances  of  common  sensation,  anaesthesia,  and 
sometimes  of  the  special  senses,  on  the  same  side  with 
the  headache,  are  less  frequent.  When  the  numbness 
is  on  the  right  side,  there  may  be  with  it  one  of  the 
forms  of  aphasia. 

In  severe  cases  it  is  impossible  for  the  patient  to 
apply  himself  mentally  ;  but  sometimes  more  than  this 
mental  disturbance  is  noticed,  though  not  to  any  serious 
extent,  even  during  the  seizures. 

Pathogenesis. — It  is  often  assumed  by  the  patient 
that  the  attacks  of  migraine  are  due  to  gastric  disturb- 
ance ;  as  the  nausea  and  vomiting  are  so  frequent,  this 
is  not  strange,  and  too  often  the  physician  falls  in  with 
this  view.  While  imprudence  in  diet  may  sometimes 
be  the  exciting  cause  of  an  attack,  it  is  only  incident- 
ally so ;  other  causes  are  equally  as  effective.  The  phe- 
nomena are  all  referable  to  cerebral  influence;  the 
nausea  is  from  the  encephalon,  not  from  the  stomach. 

Any  one  interested  in  the  different  theories  will 
find  them  fully  discussed  by  Liveing. 

There  seem  to  be  two  conditions  of  the  cerebral 
circulation  during  the  attacks ;  in  some  the  vessels  seem 
to  be  in  a  state  of  spasm,  contracted ;  in  others  dilated. 
Liveing  refers  the  attacks  to  the  explosive  tendency  to 
be  found  in  the  nervous  system  even  in  health. 

There  is  usually  no  anatomical  change  possible,  as 
the  attacks  are  so  fugitive.  Occasionally  certain  of  the 
sensory  disturbances,  as  numbness  or  visual  change, 
are  more  permanent,  so  that  a  slight  structural  change 
in  the  brain  might  be  possible.  A  change  in  the  circu- 
lation, and,  in  the  above  rare  cases,  in  the  structure  of 
the  posterior  part  of  the  inner  capsule  and  adjoining 
portion  of  the  optic  thalamus,  would  explain  the  symp- 


314  DISEASES  OF  THE  SYMPATHETIC. 

toms,  except,  perhaps,  the  headache  and  nausea.  Pro- 
visionally, we  may.  imagine  this  to  be  the  seat  of  the 
change,  though  our  actual  knowledge  in  this  regard  is 
very  slight. 

There  is  a  resemblance  between  the  attacks  of  mi- 
graine and  those  of  epilepsy,  which  it  is  not  necessary 
to  specify  minutely.  A  few  cases  have  been  observed 
in  which  migraine  in  early  life  was  later  rej)laced  by 
epilepsy. 

Peogistosis. — The  prospect  is  very  slight  of  com- 
plete immunity  from  the  attacks  during  early  life  ; 
with  advancing  years  the  frequency  of  the  paroxysms 
diminishes,  and  finally  the  patient  is  free.  Yet  much 
benefit  may  be  derived  from  treatment  in  diminishing 
the  severity  and  frequency  of  the  attacks. 

Treatment. — Such  hygienic  measures  should  be 
adopted  as  will  most  effectually  remove  the  exciting 
causes ;  over- exertion  of  the  brain,  neglect  of  proper 
exercise  and  out-door  life,  late  hours,  excitement — such 
influences  can  be  avoided  by  suflBlcient  self-denial  on 
the  part  of  the  patient  except  in  the  cases  where  the 
struggle  for  the  necessaries  of  life  demand  the  sacrifice. 
Much  can  be  done,  also,  by  means  already  alluded  to, 
to  increase  the  strength  and  vigor  of  the  nervous  sys- 
tem. 

During  the  attack  the  patient  will  instinctively  take 
the  precautions  as  to  rest  and  posture  which  are  most 
favorable.  The  friends  may,  however,  be  too  fussy. 
Quiet,  i.  e.,  freedom  from  noise,  motion.  Jarring,  and 
from  conversation  ;  exclusion  of  light ;  coolness  in  the 
atmosphere  of  the  room,  not  chilliness ;  abstinence  from 
food — these  conditions  may  be  obtained  by  the  aid  of 
friends,  or  officious  friends  may  render  it  impossible 
for  the  patient  to  have  them. 

Drugs  taken  early  in  the  attack  may  diminish  its 
severity.  Sometimes  a  large  dose  of  quinine,  ten  to 
twenty  grains,  is  of  benefit ;  caffein,  or  citrate  of  caf- 
fein,  in  two-  to  five-grain  doses,  is  more  effectual ;  prep- 


SICK  HEADACHE.  315 

arations  of  guarana  have  an  effect  similar  to  caffein. 
In  cases  of  paralysis  of  the  vaso- motor  constrictor 
nerves,  ergot  is  of  value  ;  where  there  is  spasm  of  those 
nerves,  the  inhalation  of  nitrite  of  amyl  proves  of  value, 
but  it  may  be  necessary  to  repeat  it  several  times  at 
short  intervals  ;  one  to  three  drops  may  be  inhaled ; 
when  a  patient's  peculiarities  and  susceptibility  to  the 
drug  are  known,  larger  doses  may  be  used ;  belladonna 
or  atropia  may  be  of  use  in  the  same  class  of  cases  ; 
nitro-glycerine,  or  glonoin,  as  it  is  also  called,  has  been 
recommended,  one  drop  of  the  one-per-cent  solution  be- 
ing used  in  water,  but  its  value  is  doubtful.  Chloride 
of  ammonium,  twenty  to  forty  grains,  may  diminish  the 
severity  of  the  pain.  Copious  draughts  of  hot  water 
have  been  of  value  with  some  patients.  After  the  nau- 
sea has  become  marked,  internal  remedies  are  likely  to 
increase  it,  and  add  to  the  distress  by  causing  vomiting  ; 
though,  in  rare  cases,  the  emesis  relieves  the  pain  and 
shortens  the  attack. 

Several  remedies  have  a  value  in  diminishing  the 
frequency  of  the  attacks.  Extract  of  cannabis  Indica 
in  one-third-  to  one-half -grain  doses  three  times  a  day 
is  very  valuable,  but  it  must  be  continued  several 
weeks.  Valerianate  of  zinc,  three  grains  three  times  a 
day,  is  also  useful;  and  in  larger  doses,  five  or  six 
grains  every  three  hours,  it  may  shorten  the  attack. 

Liveing  found  iodide  of  potassium,  five  grains  three 
times  a  day,  of  advantage,  and  he  also  recommends 
bromide  of  potassium.  It  should  be  given  in  ten-  to 
twenty -grain  doses  three  times  a  day  for  several 
months. 

The  galvanic  current  may  be  used  with  advantage. 
In  cases  where  the  vessels  are  contracted,  the  negative 
pole  should  be  held  in  the  hand,  or  on  the  back  of  the 
neck,  while  the  positive  pole  is  placed  over  the  cervi- 
cal sympathetic  without  interruptions.  In  cases  with 
paralysis  of  the  constrictor  vaso-motor  nerves,  Erb  ad- 
vises the  cathode  over  the  sympathetic,  and  that  the 


316  DISEASES  OF  THE  SYMP ATRETIC. 

current  should  be  repeatedly  opened  and  closed,  avoid- 
ing, however,  too  strong  irritation. 

The  faradic  current,  used  as  advised  for  simple 
headache,  sometimes  gives  relief. 

Many  times  these  applications  can  not  be  made  dur- 
ing the  attack,  as  the  pain  is  increased  by  the  simple 
manipulations  necessary,  and  not  relieved  by  the  elec- 
tricity. 

Between  the  attacks,  general  faradization  or  galvani- 
zation may  be  of  great  service,  as  in  other  cases  of  di- 
minished nervous  power,  in  restoring  the  system  to  a 
normal  condition. 

Massage  would  rarely  be  of  value  during  the  attack, 
but  in  its  incipient  stage,  and  between  the  attacks,  may 
be  of  great  benefit. 

GRAVES'S  DISEASE  (Exophthalmic  Goitre), 

EuLENBURG  und  GuTTMANN,  Die  Basedow'sclie  Krankheit. 
Arch.f.  Psych.,  i,  1868,  p.  430.— Wilks,  S.,  ExopMhalmic  Goi- 
tre. Guy's  Hosp.  Rep.,  1870,  p.  7.— Russell,  J.,  Clinical  Illus- 
trations of  Graves's  Disease.  Med.  Times  and  Gaz.,  Sept.  2, 1876 
et  seq. — Chvostek,  Die  Therapie  der  Basedow'sclie  Krankheit. 
Zeitschr.  f.  Therapie,  No.  8,  1883. 

Exophthalmic  goitre  is  an  affection  attended  with 
three  prominent  symptoms — palpitation,  goitre,  and 
exophthalmos. 

Symptoms. — The  disease  usually  begins  by  a  nerv- 
ous irritability  and  change  of  character,  feeling  of 
fullness  in  the  head  and  eyes  and  neck,  and  palpita- 
tion. In  most  cases  the  palpitation  is  spoken  of  as  the 
first  symptom,  perhaps  because  it  first  attracts  atten- 
tion. The  heart's  action  rises  to  100  or  150  ;  but  there 
are  no  signs  of  organic  disease  of  the  heart. 

The  projection  of  the  eye  is  usually  attended  with  a 
diminution  in  the  motion  of  the  upper  lid,  so  that,  if 
the  eyeball  is  rolled  upward,  the  lid  does  not  move  in 
harmony  therewith. 

Sight  is  not  affected,  and  accommodation  is  not  dis- 


GRAVES'S  DISEASE.  317 

turbed.  The  ophtlialmoscope  generally  shows  notliing 
abnormal,  though  optic  neuritis  has  been  seen. 

The  thyroid  gland  slowly  increases  in  size  until  it 
becomes  quite  prominent ;  even  the  middle  lobe  may 
be  enlarged.  In  consequence  of  this  enlargement,  the 
voice  may  be  somewhat  changed  in  character,  and  res- 
piration may  be  disturbed. 

Various  general  symj^toms  may  be  associated  -with 
the  above.  The  appetite  suffers  ;  diarrhoea  sometimes 
sets  in  ;  there  may  be  extreme  emaciation  ;  angemia  is 
not  uncommon. 

Among  women,  the  catamenia  may  cease,  or  there 
may  be  dysmenorrhoea.  There  is  sometimes  unilateral 
sweating. 

Sometimes  one  of  the  three  prominent  symptoms 
may  be  absent. 

As  a  rule,  the  symptoms  are  very  slightly  marked  at 
first,  but  gradually  increase  in  severity,  the  disease  be- 
ing chronic  in  its  course.  Occasionally  an  acute  case 
appears,  in  which  all  the  symptoms  are  rapidly  devel- 
oped. 

Pathology. — The  pathology  of  this  disease  is  by 
no  means  easy  to  explain.  Panas  is  inclined  to  think 
that  the  disease  depends  upon  a  disturbance  of  the 
medullary  oblongata,  an  irritation  which  would  excite 
the  sympathetic  fibers  passing  to  the  heart,  and  the 
vaso-dilator  nerves  would  explain  the  symptoms.  Or, 
on  the  contrary,  a  paralysis  of  the  inhibitory  nerves, 
and  of  the  vaso-constrictures.  Panas  is  inclined  to 
the  belief  that  the  latter  is  the  correct  explanation. 

Anatomical  changes  have  been  found  several  times 
in  the  cervical  sympathetic,  especially  in  the  lower 
ganglion. 

Peogistosis.  — Prognosis  is  not  very  favorable,  though 
several  cases  of  recovery  have  been  reported. 

Teeatment. — Digitalis  has  but  little  influence  in 
moderating  the  rapidity  of  the  heart's  action.  Bella- 
donna has  sometimes  been  of  use.     Quinine  and  iron 


318  DISEASES  OF  THE  SYMPATHETIC. 

have  also  proved  serviceable.  The  best  results  have  been 
obtained  by  Chvostek  from  the  use  of  electricity.  He 
used  the  ascending  galvanic  current  to  the  cervical  sym- 
pathetic, and  on  each  side,  stabile,  one  minute  ;  to  the 
spinal  cord  the  positive  pole  on  the  fifth  dorsal,  the 
negative  on  the  cervical  vertebrae ;  he  also  passed  a  cur- 
rent transversely  through  the  head  from  one  mastoid 
process  to  the  other ;  or  in  some  cases  applied  it  to  the 
temples.  The  application  was  about  one  minute  in 
each  place.  He  used  a  very  weak  current,  which  caused 
no  sense  of  heat,  and  applied  it  daily. 

Meyer  and  Leube  have  both  obtained  good  results 
from  galvanism. 

ANGINA  PECTORIS. 

See,  G.,  De  I'angine  de  poitrine,  France  med.,  1876,  p.  197 
et  seq. — Balfour,  G-.  W.,  Upon  Paroxysmal  Angina  Pectoris, 
Edinburgh  Med.  Jour.,  March,  1881,  p.  769.— Huchaed,  H.  Le 
concours  med.,  No.  6,  1884. 

Angina  pectoris  is  a  disease  characterized  by  pain- 
ful paroxysms,  the  pain  being  situated  in  the  neighbor- 
hood of  the  heart,  and  radiating  thence  to  the  left  side 
of  the  chest  and  left  arm.  The  attacks  are  accompa- 
nied with  great  anxiety  and  a  sensation  of  impending 
dissolution. 

Etiology. — The  disease  attacks  males  by  prefer- 
ence, and  occurs  most  frequently  after  the  age  of  forty. 
It  is  uncertain  whether  heredity  plays  any  part  in  the 
aetiology  of  this  disease.  Gout,  rheumatism,  and  alco- 
holism are  supposed  to  be  important  as  causes.  Ex- 
cessive tobacco-smoking  is  also  spoken  of  as  predispos- 
ing to  the  disease.  Many  cases  of  angina  pectoris  are 
found  in  persons  who  have  organic  diseases  of  the 
heart,  and  these  are  naturally  looked  upon  as  giving  rise 
to  the  pain.  Especially  is  this  true  in  regard  to  changes 
in  the  coronary  arteries,  or  such  changes  at  the  com- 
mencement of  the  aorta  as  are  likely  to  interfere  with 


ANGINA  PECTORIS.  319 

the  circulation  of  the  blood  through  the  substance  of 
the  heart. 

As  dkectly  exciting  to  the  attacks  may  be  men- 
tioned exposure  to  cold,  unusual  mental  emotions  and 
bodily  exertion,  esiDecially  walking  against  a  strong 
wind,  or  walking  rapidly  up  hill,  or  ascending  a  flight 
of  steps  rapidly.  Yet  many  cases  occur  in  which  there 
has  been  no  special  exciting  cause,  as  is  particularly 
true  of  those  attacks  which  occur  during  sleep. 

Pathological  Anatomy. — The  anatomical  changes 
found  are  such  as  belong  to  the  organic  diseases  of  the 
heart,  which  may  be  supposed  to  exert  an  influence  as 
predisposing  causes.  Otherwise  than  these  changes, 
which  need  no  special  description,  there  is  no  anatomi- 
cal lesion  discoverable. 

Symptoms. — The  prominent  symptom  of  this  dis- 
ease is  pain,  which  is  situated  usually  along  the  left 
border  of  the  sternum,  and  more  especially  near  the 
apex  of  the  heart.  Thence  the  pain  may  radiate  over 
the  whole  chest,  may  descend  along  the  left  arm,  rarely 
going  below  the  elbow.  The  pain  is  not  so  sharp  and 
acute  as  some  other  species  of  neuralgia,  but  it  is  at- 
tended with  such  anxiety  and  distress,  such  a  sense  of 
danger  to  life,  that  it  is  much  less  bearable  than  almost 
any  other  variety  of  pain. 

During  the  attack  the  pulse  is  often  increased  in 
rapidity,  but  is  rarely  irregular  unless  there  is  organic 
cardiac  disease.  The  respiration  is  sometimes  unaf- 
fected, though  very  often  the  patient  instinctively  holds 
his  breath,  and  remains  immovable,  supporting  himself 
by  Ms  arms,  as  if  afraid  even  to  breathe.  Each  attack 
of  severe  pain  is  usually  of  but  short  duration ;  but 
they  may  succeed  one  another  rapidly,  and  the  duration 
of  the  whole  attack  is  very  variable,  sometimes  extending 
over  days,  though  when  so  long  there  are  generally  pe- 
riods of  remission  almost  amounting  to  intermission. 

When  the  attack  has  finally  ceased,  the  patient  is 
usually  free  from  pain  until  the  recurrence  of  the  next, 


320  DISEASES  OF  THE  SYMPATHETIC. 

wMcli  may  not  be  for  many  montlis ;  but,  as  tlie  at- 
tacks recur,  their  frequency  becomes  greater,  until  the 
intervals  between  are  very  short. 

Peognosis. — When  the  disease  depends  upon  an 
organic  change  of  the  heart,  death  usually  follows  after 
a  longer  or  shorter  interval.  Where  there  is  no  organic 
change  of  the  heart,  the  patient  may  recover,  and  live 
long  without  a  recurrence  of  the  disease. 

The  nature  of  the  disease  is  but  imperfectly  known. 
It  is  generally  considered  as  belonging  to  the  neural- 
gias. Some  cases  are  referable  to  gout  or  rheumatism  ; 
some  are  probably  due  to  fatty  degeneration  of  the 
walls  of  the  heart.  Some  again,  perhaps,  depend  upon 
an  imperfect  supply  of  blood  to  the  heart,  in  conse- 
quence of  disease  of  its  nutrient  arteries.  It  has  also 
been  referred  to  a  neuritis  of  the  cardiac  nerves:  As 
has  been  remarked  :  "It  is  very  difficult  to  choose  an 
opinion  out  of  the  midst  of  this  labyrinth  of  explana- 
tions, which  contradict  each  other  and  destroy  each 
other." 

DiAGisrosis. — The  chief  danger  of  mistake  lies  rather 
in  considering  a  simple  neuralgia,  affecting  the  inter- 
costal nerves,  as  angina  pectoris. 

The  character  of  the  pain  is  different,  the  anxiety 
and  distress  attending  it  are  much  less  in  intercostal 
neuralgia,  or  are  entirely  wanting. 

Embolism  of  the  pulmonary  artery  is  attended  with 
much  greater  dyspnoea,  and  the  circumstances  asso- 
ciated with  it  will  assist  to  a  diagnosis. 

It  is  of  primary  importance  to  learn  whether  the 
pain  is  associated  with  organic  disease  of  the  heart. 
To  do  this,  it  would  be  necessary  to  examine  the  heart 
between  paroxysms.  And  even  a  careful  physical  ex- 
amination may  not  settle  the  question  without  doubt. 

Treatment. — Eulenburg  says  :  "  The  remedies  are 
many,  the  cures  few,"  During  the  pal'oxysm  it  is 
most  important  to  relieve  the  pain  and  distress. 

Nitrite  of  amyl  wiU  sometimes  cut  the  attack  short. 


ANGINA  PECTORIS.  321 

Five  or  six  drops  on  a  liandkerchief ,  inhaled  by  the  pa- 
tient, repeated  if  necessary,  may  suffice  to  relieve  the 
paroxysm. 

The  subcutaneous  injection  of  morphia,  with  a  small 
amount  of  atropia,  wiU  often  give  relief.  With  other 
patients,  the  most  speedy  relief  is  experienced  from 
the  application  of  ice  immediately  over  the  heart.  Ni- 
tro-glycerine  (glonoin),  in  the  dose  of  one  or  two  drops 
of  the  one-per-cent  solution,  has  been  recommended, 
and  has,  in  some  cases,  proved  very  efficacious,  not  only 
in  relieving  the  pain  of  the  attack,  but  iq  warding  off  a 
recurrence. 

Aconitia,  by  preference  Duquesnil's,  in  dose  of  from 
^1^  to  ^fo  of  a  grain,  repeated,  if  necessary,  every  hour 
or  two  hours,  until  there  is  tingling  of  the  lips,  or 
tongue,  or  fingers,  will  often  give  relief,  but  is  less 
rapid  in  its  action  than  the  remedies  previously  men- 
tioned. The  benefit  derived  from  this  drug  is,  however, 
of  longer  duration.  Tincture  of  aconite-root  may  be 
used  instead. 

Between  the  attacks  means  should  be  taken  to  di- 
minish the  danger  of  a  recurrence.  If  there  is  any 
gout  or  rheumatic  tendency,  appropriate  remedies 
should  be  used.  In  other  cases  the  general  health 
should  be  maintained,  the  patient  cautioned  against 
over-exertion  of  any  kind,  and,  as  many  of  these  pa- 
tients are  run  down  in  general  health  and  overtaxed, 
a  large  proportion  of  rest  is  absolutely  necessary. 
Smoking  should  be  given  up. 

Among  the  drugs  which  may  be  used  with  the  pros- 
pect of  greatest  benefit  is  arsenic.  Besides  this,  prepa- 
rations of  iron  and  zinc  may  be  used.  Mtrate  of  silver 
has  been  recommended.  Digitalis,  combined  with  the 
arsenic,  is  also  mentioned  as  valuable. 

21 


322  DISEASES  OF  THE  SYMPATHETIC. 


SYMMETRICAL  GANGRENE. 

Raynaud,  M.,  Nouvelles  recherches  suf  la  nature  et  le  traite- 
ment  de  I'asphyxie  locale  des  extremites.  Arch.  gen.  de  med., 
1874,  Jan.,  p.  1 ;  Feb.,  p.  189.— Warren,  J.  C,  Symmetrical  Gan- 
grene of  the  Extremities.  Boston  Med.  and  Surg.  Jour.,  Jan.  16, 
1879,  p.  76. — Weiss,  M.,  Ueber  sogenannte  symmetriscbe  Gan- 
gran.    Zeitschr.f.  Heilk.,  iii,  1882,  p.  233. 

The  causes  of  this  peculiar  affection  are  not  known. 
The  disease  consists  in  a  disturbance  of  the  circulation, 
especially  in  the  extremities,  probably  an  affection  of 
the  vaso-motor  nerves,  by  which  the  supply  of  blood  is 
cut  off,  and  hence  the  nutrition  suffers  ;  and,  when  car- 
ried to  an  extreme,  gangrene  sets  in,  and  the  affected 
parts  slough  off.  Fingers  and  toes  are  the  most  fre- 
quently affected ;  but  limited  spots  on  the  body,  and 
even  the  face,  may  suffer.  The  disease  is  almost  al- 
ways symmetrical,  and  is  paroxysmal. 

In  many  patients  there  is  a  prodromic  period  of  un- 
rest, with  change  of  character.  The  patient  becomes 
peevish,  fretful,  surly,  withdraws  within  himself,  and 
avoids  contact  with  those  whom  he  formerly  sought, 
even  his  own  children.  He  sighs,  and  frequently  sheds 
tears.  Sleep  is  restless,  broken  by  dreams.  Appetite 
poor,  digestion  difficult,  and  the  slightest  excess  is  fol- 
lowed by  severe  gastric  crises,  similar  to  those  seen  in 
ataxia.     Hearing,  sight,  and  taste  may  be  diminished. 

A  disagreeable  sensation  is  felt  in  the  limbs ;  the 
circulation  is  sluggish  ;  the  surface  becomes  cyanotic, 
perhaps  almost  black  ;  generally,  severe  pain,  of  a  neu- 
ralgic character,  sets  in,  which  is  without  intermission, 
almost  without  remission.  The  affected  parts  are  an- 
aesthetic, and  this  may  cause  the  gait  to  assume  an 
ataxic  character. 

After  reaching  this  stage,  the  symptoms  may  sub- 
side and  the  normal  condition  of  the  parts  return. 
Otherwise,  the  disturbance  of  nutrition  increases,  and 
there  is  gangrene  affecting  the  fingers  and  toes,  or  su- 


8TMMETRIGAL   GANGRENE.  823 

perficial  spots  of  tlie  skin,  and  after  four  or  five  days 
the  dried  epidermis  falls  off,  leaving  a  superficial  ulcer, 
wliicli  heals  slowly.  If  a  whole  phalanx  of  finger  or 
toe  is  affected,  this  drops  off,  and  the  stump  cicatrizes 
slowly. 

There  is  no  fever  attending  the  above  phenomena. 
The  heart  is  unaffected  ;  the  pulse  is  not  disturbed,  even 
in  the  arteries  near  the  cyanotic  parts.  The  tempera- 
ture is  lowered  in  the  affected  limbs.  Occasionally 
there  is  no  pain. 

Raynaud  found  the  circulation  of  the  fundus  of  the 
eyes  affected,  arteries  contracted,  and  venous  pulsation  ; 
in  one  case  he  found  these  changes  between  the  attacks ; 
in  another  case  at  the  same  time  with  the  attacks. 

The  diagnosis  is  not  difficult  when  the  whole  series 
of  symptoms  is  before  one  ;  but  at  the  beginning  there 
might  be  some  doubt  as  to  the  nature  of  the  affection, 
and  it  would  be  excusable  to  suspect  locomotor  ataxia, 
or  disease  of  the  spinal  membrane. 

Teeatment. — Warmth  and  rest  are  indicated  ;  some 
of  the  symptoms  might  be  relieved  by  gentle  massage. 

Raynaud  obtained  excellent  results  from  the  use  of 
the  galvanic  current  applied  over  the  spinal  column. 
He  used  from  twenty-five  to  thirty  cells,  the  positive 
pole  over  the  fifth  cervical  vertebra,  the  negative  pole 
over  the  sacrum.  After  a  short  time  he  slid  the  nega- 
tive pole  lip  to  the  eighth  dorsal  vertebra.  The  appli- 
cation was  continued  ten  to  fifteen  minutes  daily.  The 
circulation  became  more  rapid ;  abundant  sweat  ap- 
peared ;  the  hands  became  moist ;  in  some  cases  head- 
ache followed  the  application,  and  then  it  was  neces- 
sary to  reduce  the  number  of  cells.  He  also  applied 
the  positive  pole  over  the  nerves  in  the  upper  part  of 
the  limb,  and  the  negative  pole  over  the  affected  sur- 
face. He  was  able  to  use  in  this  way  from  thirty  to 
sixty  cells.  As  improvement  appeared,  sensation  be- 
came more  acute,  and  it  was  necessary  to  reduce  the 
number  of  cells. 


324:  DISEASES  OF  THE  SYMPATHETIC. 

UNILATERAL  FACIAL  ATROPHY. 

GUTTMAOTT,  P.,  Ueber  einseitige  Gesichtsatrophie.  Arch.  f. 
Psych.,  i,  1868,  p.  173.— Bannister,  H.  M.,  Progressive  Facial 
Hemiatrophy.  Jour,  of  Nervous  and  Mental  Diseases,  Oct.,  1876, 
p.  539.— Hammond,  Wm.  A.  Ihid.,  April,  1880,  p.  250.— Flashar, 
Ein  Fall  von  bilateraler  neurotischer  Gesichtsatrophie.  Berl.  M. 
Woch.,  Aug.  2,  1880,  p.  441.— Wette,  H.  CM.  f.  d.  m.  Wissen., 
July  8,  1882,  p.  491. — Mendel.  Berlin.  M.  Wochenschr.,  Sept.  17, 
1883,  p.  588.— Jessop  and  Browne.  St.  Barthol.  Hosp.  Rep.,  xviii, 
1882. — Wolff,  Ueber  doppelseitige  fortschreit.  Gesicbtsatrophie. 
Virch.  Arch.,  94,  1883,  p.  393. 

The  cause  of  unilateral  atrophy  of  the  face  is  not 
certain ;  more  cases  have  been  noticed  in  women  than 
in  men ;  frequently  injuries  have  preceded  the  atro- 
phy. 

Symptoms. — Preceding  the  change  in  the  tissues  of 
the  face  there  may  be  a  prodromic  period,  during 
which  there  is  pain  in  the  face  and  head,  with  perhaps 
hypersesthesia.  Bannister  noticed  absence  of  perspira- 
tion on  the  affected  side  of  the  face,  without  pain. 

Before  the  atrophy,  there  is  usually  a  whitish  dis- 
coloration of  the  skin  at  the  point  where  the  change  is 
about  to  take  place.  Two  or  three  of  these  spots  may 
appear  at  a  moderate  distance  from  one  another,  and  run 
together.     The  hair  becomes  white,  and  may  fall  out. 

The  atrophy  affects  the  skin  and  subcutaneous  tis- 
sues ;  the  bones  rarely  undergo  atrophy,  though  their 
growth  may  be  retarded  if  the  patient  has  not  reached 
adult  years.  The  muscles  of  the  face  are  not  subject  to 
any  fatty  degeneration.  Hammond  found  the  muscu- 
lar fibers  diminished  in  size.  Owing  to  the  loss  of  fat 
tissue  and  change  in  the  skin,  the  cheek  is  hollowed  in  ; 
the  skin,  lacking  in  elasticity,  seems  to  be  closely  ad- 
herent to  the  bone.  Sometimes  the  tongue,  the  hard 
and  soft  palate,  are  affected  ;  the  eye  seems  to  be  sunken 
deeper  into  its  socket,  and  the  lids  are  partially  closed. 

There  is  no  muscular  paralysis  ;  the  electrical  reac- 
tions are  normal ;  the  circulation  is  rarely  disturbed ; 


UNILATERAL  FACIAL  ATROPHY.  325 

there  is  no  change  of  temperature  on  the  two  sides  of 
the  face  ;  tactile  sensation  is  not  diminished. 

The  disease  does  not  lead  to  a  fatal  result,  and  no  au- 
topsies have  been  made.  Several  theories  have  been 
advanced  to  explain  the  singular  phenomena.  It  has 
been  thought  to  be  a  disease  of  the  cervical  portion  of 
the  sympathetic,  or  of  the  nuclei  of  the  facial  or  other 
cranial  nerve ;  of  the  spheno-palatine  ganglion,  or  a 
primitive  atrophy  of  the  adipose  tissue. 

No  treatment  has  been  of  permanent  benefit.  Elec- 
tricity has  been  thought  to  give  a  slight  relief.  Both 
the  galvanic  and  faradic  current  have  been  applied 
locally  to  the  face,  but  no  permanent  improvement  fol- 
lowed. 


UNCLASSIFIED. 


CHAPTER  XXyiL 

VEETIGO. 

Russell,  J. ,  Illustrations  of  Stomachic  Vertigo  and  Allied  Af- 
fections. Med.  Times  and  Gaz.,  July  3,  1880.— Jackson,  J.  H., 
Lecture  on  Auditory  Vertigo.  Lancet,  Oct.  3,  1880,  p.  525. — 
Fere,  Ch.,  et  Demars,  A.,  Note  sur  la  maladie  de  Meniere  et  en 
particulier  sur  son  traitement  par  la  methode  de  M.  Charcot. 
Revue  de  med.,  No.  10,  1881. — Leven,  Du  -i^ertige.  Gaz.  des  hop., 
May  23,  1882,  p.  468. — Woakes,  E.,  Remarks  on  Vertigo.  Brit. 
Med.  Jour.,  April  28,  1883,  p.  801. 

Frank  defines  vertigo  as  "an  illusional  turning,, 
painful  and  sudden,  which  seems  to  affect  the  person 
himself  and  external  objects,  whether  they  are  in  re- 
pose or  moving  in  their  ordinary  manner." 

Vertigo  is  reaEy  a  symptom,  not  a  disease.  It  may 
be  reflex  or  sympathetic,  or  the  cause  may  escape  our 
observation,  and  then  it  is  spoken  of  as  idiopathic. 

Axenfeld  has  said  that  vertigo  is  caused  by  a  change 
in  the  intra-cranial  circulation,  either  a  lack  of  suffi- 
cient arterial  blood,  or  hypersemia,  causing  the  symp- 
tom. In  both  these  conditions  the  molecular  inter- 
change in  nerve-cells  is  incomplete  ;  their  nutrition  suf- 
fers ;  their  functions  are  exalted,  exhausted,  or  per- 
verted. 

Causes. — Vertigo  is  sometimes  caused  by  dyspep- 
sia. It  is  one  of  the  symptoms  of  exhaustion,  of  cere- 
bral anaemia,  of  intestinal  or  uterine  disturbance.  Va- 
rious poisons  may  produce  vertigo,  as  tobacco,  alcohol, 
opium,  oxide  of  carbon,  lead,  prussic  acid,  or  ursemic 
poisoning.  It  is  very  common  in  certain  cerebral  dis- 
eases, especially  those  affecting  the  cerebellum.    Heart 


330  UNCLASSIFIED. 

disease  is  sometimes  accompanied  by  vertigo.  It  may 
be  premonitory  of  various  acute  diseases,  as  tlie  exan- 
themata. The  petit  mal  of  epilepsy  is  often  simply 
vertigo  attended  with  impaired  consciousness. 

A  disturbance  of  accommodation  in  the  eyes,  espe- 
cially if  the  eyes  differ  one  from  the  other,  may  give 
rise  to  this  disagreeable  symptom.  A  slight  weakness 
of  some  of  the  motor  muscles  of  the  eye,  producing 
slight  strabismus,  may  have  the  same  effect.  Of  these, 
the  causes  are  comparatively  simple,  and  require  little 
more  than  a  mention.  There  is,  however,  a  series  of 
symptoms,  due  to  disturbances  of  the  ear,  which  de- 
serve more  extended  mention. 

Disease  of  the  s^emicircular  canals,  or  even  a  slight 
increase  of  pressure  upon  the  fluid  contained  in  these 
canals,  is  attended  with  vertigo.  Even  au  accumula- 
tion of  wax  in  the  ear,  or  the  closure  of  the  Eustachian 
tube,  may  be  sufficient  to  give  rise  to  the  symptoms. 

Vertigo,  when  caused  by  affection  of  the  ear,  was 
carefully  described  by  Meniere,  and  hence  has  been 
called,  from  him,  Meniere's  disease. 

Besides  vertigo,  there  is  usually  tinnitus,  also  deaf- 
ness, which  in  severe  cases  is  complete. 

The  attack  is  often  sudden,  the  patient  being  obliged 
to  stop,  immediately  seize  hold  of  some  object  to  sup- 
port himself,  or  perhaps  he  falls,  as  if  suffering  from  an 
attack  of  epilepsy.  There  is,  however,  no  loss  of  con- 
sciousness. His  face  is  pale,  his  skin  is  cold,  he  is 
bathed  in  perspiration.  There  is  nausea,  vomiting,  and 
headache.  Many  times  the  attack  is  less  severe — the 
patient  simply  staggers  instead  of  falling,  and  suffers 
severely  from  the  accompanying  symptoms.  As  a  rule, 
the  attack  is  not  of  long  duration.  The  patient  regains 
his  steadiness  and  his  usual  health  ;  but,  so  long  as  the 
affection  of  the  ear  continues,  there  is  danger  of  a  re- 
newal of  the  vertigo. 

The  treatment  of  auditory  vertigo  is,  of  course,  first 
to  remove  any  affection  of  the  ear,  any  cause  of  press- 


VERTIGO.  331 

ure  upon  the  semicircular  canals.  Charcot  found  great 
benefit  from  the  use  of  seven  to  fifteen  grains  of  qui- 
nine daily  for  nearly  three  months.  If  necessary,  the 
quinine,  after  having  been  omitted,  can  be  repeated 
when  the  symptoms  recur. 

Sometimes  electricity  may  be  of  benefit,  though  very 
rarely. 

It  is  important  to  make  a  correct  diagnosis  as  to  the 
cause  of  vertigo.  Auditory  vertigo  is  very  likely  to  be 
mistaken  for  epilepsy,  or  for  vertigo  associated  with 
dyspepsia.  Unless  a  correct  diagnosis  of  the  cause  is 
made,  the  treatment  is  likely  to  be  futile. 

The  treatment  of  other  forms  of  vertigo  must  be  di- 
rected, according  to  the  cause,  to  the  primary  disease. 


CHAPTER  XXVIII. 

CHOEEA. 

Stueges,  O.,  Some  Statistics  of  Fatal  Chorea.  Lancet,  July 
17,  1880,  p.  85. — Mitchell,  S.  Weir,  Lectures  on  Diseases  of  the 
Nervous  System.  Lectures  Vll,  VIII.  Philadelphia,  1881. — 
Strange,  W.,  Notes  of  100  Cases  of  Chorea.  Brit.  Med.  Jour., 
July  16,  1881.— Sturges,  O.,  The  Heart  Symptoms  of  Chorea. 
Brain,  July,  1881,  p.  164. — Chapin,  H.  D.,  Points  of  Interest  in 
Chorea.  Med.  Record,  Dec.  15,  1883,  p.  648.— Santini,  G.,  Sulla 
patogenesi  della  corea.  Rivista  Sperimentale,  ix,  1883,  p.  449.  — 
Sturges,  O.,  Chorea  with  Rheumatism.  Lancet,  Aug.  31,  1878, 
Nov.  29, 1879,  Sept.  20, 1884.— Houghton,  J.  H.  Brit.  Med.  Jour., 
Dec.  9,  1882.— RiCKARDS,  E.  Ibid.,  Nov.  11,  1882,  p.  932.— Era- 
ser, T.  R.     Ibid.,  Dec.  9,  1882,  p.  1132. 

Chorea  (Saint  Yitus's  dance)  may  be  defined  as  a 
neurosis  affecting  tlie  voluntary  muscles,  generally  pre- 
ceded and  attended  with,  slight  mental  disturbances, 
the  motor  phenomena  consisting  in  irregularity  of  vol- 
untary motions,  or,  when  severe,  the  spontaneous  de- 
velopment of  irregular  motions  ax)art  from  the  inter- 
vention of  the  will. 

JEtiology. — Certain  constitutional  conditions  un- 
doubtedly predispose  to  chorea.  Heredity  seems  in 
some  cases  to  be  one  of  the  predisposing  causes  ;  the 
instability  of  the  nervous  system  at  certain  periods  of 
life,  as  during  second  dentition,  and  at  puberty,  are 
also  to  be  taken  into  account,  many  more  cases  occur- 
ring from  six  to  eleven  years  of  age  than  at  any  other 
equal  period.  The  disease  is  extremely  rare  after  twen- 
ty-five years  of  age.  The  debility  following  scarlatina, 
dii)htheria,  typhoid  fever,  etc.,  frequently  seems  to 
predispose  to  the  disease.     Rheumatism  appears  to  be- 


CHOREA.  333 

long  rather  to  the  exciting  causes,  considering  the  fre- 
quency with  which  it  is  followed  by  chorea.  The  re- 
lation which  the  two  diseases  bear  one  to  the  other  is 
still  an  undecided  question ;  they  occur  together  too 
frequently  to  justify  us  in  considering  the  relation 
purely  accidental.  Chorea  may  appear  before  the  child 
recovers  from  the  rheumatism. 

The  restraint  and  discipline  of  school  life,  especially 
public-school  life,  with  its  ambitions,  oftentimes  has 
an  injurious  influence. 

Among  the  more  immediate  causes  of  chorea  may 
be  mentioned  sorrow,  care,  anxiety,  fright,  and  irrita- 
tion. Occasionally  chorea  occurs  during  pregnancy, 
especially  among  primiparse,  and  most  frequently  dur- 
ing the  twenty-first  and  twenty-third  years  of  age. 

Symptoms. — The  earliest  symptom  is  a  change  of 
disposition.  The  child  becomes  restless,  irritable,  is 
thought  to  be  getting  nervous,  or  to  have  the  fidgets. 
It  loses  its  temper  more  easily,  gives  impertinent  and 
saucy  replies  to  its  parents  ;  in  fact,  the  whole  nature 
of  the  child  seems  to  have  undergone  a  decided  change 
for  the  worse.  Much  too  frequently  the  parents  and 
teachers  consider  the  child  disobedient  and  naughty, 
whereas  it  is  entirely  irresponsible  for  its  conduct,  and, 
instead  of  taking  the  proper  measures  to  stop  the  dis- 
ease at  its  very  beginning  by  curing  a  physical  malady, 
they  make  it  worse  by  employing  reproof,  punishment, 
and  harshness  to  correct  a  moral  delinquency  that  does 
not  exist.  This  change  of  disposition  may  continue 
throughout  the  disease,  and  even  extend  beyond  the 
time  when  motor  disturbances  have  ceased.  During 
the  severest  attacks  there  may  be  lack  of  mental  pow- 
er, and  inability  or  disinclination  to  apply  the  mind 
vigorously ;  the  expression  of  the  patient  may  be  al- 
most idiotic. 

After  the  above  mental  symptoms  have  existed  a 
variable  length  of  time,  motor  disturbance  makes  its 
appearance,  as  a  rule  beginning  on  one  side  and  ex- 


334  UFGLASSIFIED. 

tending  to  the  opposite  side.  Some  authors  say  that 
the  left  side  is  the  more  frequently  affected.  Occa- 
sionally the  motor  disturbance  is  confined  to  one  side 
during  the  entire  disease.  At  first  the  irregular  motion 
is  slight,  scarcely  perceptible  to  an  ordinary  observer  ; 
this  irregular  action  of  the  muscles  becomes  more 
marked  and  constant.  The  face  and  upper  extremities 
are  in  constant  motion  ;  the  patient  is  continuously 
making  grimaces,  which  at  first  may  be  thought  volun- 
tary, and  the  child  may  be  unjustly  punished  for 
' '  making  faces. ' '  The  fingers  are  flexed  and  extended, 
one  or  several  at  a  time  ;  the  child  picks  at  its  clothing, 
pulling  and  perhaps  tearing  it.  When  the  lower  ex- 
tremities are  affected,  the  toes  and  legs  are  in  constant 
motion,  like  the  hands.  Voluntary  motion  is  inter- 
fered with ;  the  child  is  unable  to  write  or  sew ;  often 
can  not  feed  itself.  Walking  may  also  be  difficult,  or 
impossible.  In  e::^ treme  cases,  not  only  are  the  limbs 
and  face  affected,  but  the  body  may  also  be  turned  and 
twisted  and  bent  in  various  directions  by  the  involun- 
tary action  of  the  muscles  of  the  trunk.  The  patient 
is  unable  to  be  up,  is  tossed  about  in  bed  ;  the  constant 
and  violent  motion  causes  excoriation  of  the  skin  ;  he 
has  a  wan  and  haggard,  perhaps  a  half -idiotic  look, 
and  is  a  pitiable  sight.  The  respiration  in  severe  cases 
is  sometimes  affected,  acquiring  a  jerky  character; 
speech  may  partake  of  the  same  jerky  character,  and 
it  may  even  be  almost  impossible  for  the  patient  to 
speak. 

Except  in  very  severe  cases,  sleep  is  not  disturbed, 
and  almost  invariably  the  involuntary  motions  cease 
during  sleep.  In  cases  of  moderate  severity  the  pa- 
tients do  not  complain  of  being  tired,  and  there  is  no 
appearance  of  exhaustion.  Of  course,  this  is  not  true 
of  the  severest  cases. 

Sensation  is  but  little  if  at  all  affected ;  once  in  a 
while  there  may  be  pain,  and  sometimes  tenderness,  on 
pressure  over  the  nerves. 


CHOREA.  335 

M.  Rosentlial  found  that  the  reaction  of  the  muscles 
to  both  the  faradic  and  galvanic  current  was  frequently- 
increased. 

It  is  very  common  to  find  a  cardiac  murmur  in  cases 
of  chorea,  even  where  there  has  been  no  rheumatism 
preceding.  It  is  not  very  rare  to  find  an  irregular  in- 
termission of  the  pulse.  As  the  patient  recovers,  the 
cardiac  symptoms  disappear,  unless  caused  by  organic 
lesion. 

A  so-called  post-hemiplegic  chorea  is  one  of  the 
sequelae  of  cerebral  disease.  The  motions  may  very 
closely  resemble  those  of  chorea.  This  has  been  de- 
scribed in  connection  with  cerebral  diseases. 

When  the  disease  is  caused  by  fright,  and  occasion- 
ally under  other  circumstances,  the  motor  symptoms 
show  great  intensity  at  the  commencement,  the  most 
violent  irregular  action  appearing  in  the  course  of  a  few 
hours.     These  cases,  however,  are  exceptional. 

DuEATioisr. — The  duration  of  chorea  differs  greatly 
in  different  cases.  Some  patients  recover  in  three  or 
four  weeks ;  in  others  the  disease  is  extended  over 
several  years  ;  the  average  duration  is  said  to  be  two  or 
three  months.  It  is  not  uncommon  for  a  child  to  suffer 
from  two  or  even  three  attacks.  Between  these  attacks 
the  child  is  considered  well,  and  is  thought  to  have 
been  cured  ;  but  many  times  a  careful  observation  will 
show  that  the  irritability  of  the  temper  and  changed 
disposition  persist ;  also,  if  the  child' s  hand  is  quietly 
held,  a  very  slight  spasmodic  action  of  the  fingers  can 
be  felt — too  slight,  perhaps,  to  be  seen. 

Many  cases,  therefore,  spoken  of  as  recurrence  of 
chorea,  are  in  reality  simply  cases  of  remission  of  the 
severer  symptoms.  Dr.  Mitchell  mentions  the  greater 
frequency  of  chorea  in  the  spring,  and  a  tendency  to 
recur  the  succeeding  spring. 

Diagnosis. — The  milder  cases  of  chorea  can  hardly 
be  mistaken,  especially  if  their  history  is  learned  ;  the 
d^escription  of  the  disease  already  given  is  sufficient  for 


336  UNCLASSIFIED. 

diagnosis.  There  is  a  form  of  choreic  disturbance  which 
occurs  after  apoplexy,  affecting  the  paralyzed  side, 
which  might  be  mistaken  for  genuine  chorea.  Charcot 
has  well  described  this,  and  named  it  post-hemiplegic 
chorea.  A  history  of  the  case  showing  the  previous 
attack  of  paralysis,  the  fact  that  the  affected  limb  still 
suffers  from  impaired  power,  and  the  difference  between 
the  involuntary  motions  in  these  cases  and  the  irregu- 
lar action  seen  in  genuine  chorea,  together  with  fre- 
quent presence  of  contraction,  would  assist  in  forming 
a  diagnosis  between  the  two  conditions. 

In  a  few  cases  of  cerebro-spinal  sclerosis  the  irregu- 
lar involuntary  motions  become  so  general,  and  reach 
such  a  grade  of  severity  toward  the  close  of  the  dis- 
ease, that  it  is  possible  to  mistake  the  affection  and 
consider  that  the  patient  is  suffering  from  chorea.  In 
these  cases  the  history  of  the  disease  and  the  general 
character  of  the  motions,  the  fact  that  sensation  is  often 
affected  in  sclerosis,  that  contraction  of  the  fingers  and 
hand  are  more  frequent,  will  aid  in  forming  a  correct 
diagnosis.  These  cases  are,  however,  often  very  diffi- 
cult to  distinguish  from  chorea. 

Pathological  Anatomy. — The  nature  and  seat  of 
the  lesion  causing  chorea  are  still  undecided  questions. 
Mild  cases  recover,  leaving  no  disability ;  only  severer 
cases  result  in  death :  and  therefore  it  is  not  without 
reason  that  many  authors  object  to  ascribing  the  milder 
cases  to  the  same  lesion  as  is  found  in  the  severer  cases. 
In  many  autopsies  the  smaller  blood-vessels  of  the  brain 
have  been  found  plugged.  In  some  cases  minute  vege- 
tations have  been  found  on  the  valves  of  the  heart,  ac- 
counting for  the  embolisms  in  the  brain ;  but  these 
changes  are  not  constant.  The  optic  thalamus  and  cor- 
pus striatum  are  the  parts  chiefly  or  exclusively  affected. 

It  is  specially  interesting  to  recall  the  fact  that  in 
post-hemiplegic  chorea,  and  in  so-called  athetosis,  the 
lesions  preceding  these  irregular  motions  are  situated 
in  the  same  portions  of  the  brain  in  which  these  dis- 


CHOREA.  337 

eased  arteries  are  found  in  chorea.  Whether  this  por- 
tion of  the  brain  is  affected  in  sclerosis  with  exagger- 
ated tremor  has  not,  to  my  knowledge,  been  a  subject 
of  investigation.  It  is  also  an  interesting  fact  that  bun- 
dles of  nerve-fibers,  passing  through  this  region  from 
the  cortex,  may  be  irritated  so  as  to  produce  move- 
ments in  the  limbs  similar  to  those  produced  by  irrita- 
tion of  the  motor  centers  in  the  cortex. 

There  is,  therefore,  a  presumption  in  favor  of  a  simi- 
lar causation  of  the  irregular  movements  in  all  these 
affections.  Whether  the  mild  cases  of  chorea,  ending 
in  complete  recovery,  can  ever  be  referred  to  an  organic 
lesion  of  the  brain,  is  extremely  doubtful.  A  simple 
functional  disturbance  is  sufficient  to  account  for  all  the 
symptoms.  Considering  the  mental  phenomena,  and 
the  frequent  hemiplegic  character  of  the  disease,  af- 
fecting the  face  as  well  as  the  limbs,  it  must  be  looked 
upon  as  primarily  of  cerebral  origin. 

Pkognosis. — There  is  very  little  more  to  be  said  in 
regard  to  prognosis ;  the  milder  cases  always  recover 
after  a  variable  length  of  time,  perhaps  after  two  or 
three  relapses.  The  older  the  child  at  the  beginning  of 
the  disease,  the  more  severe  will  it  probably  be,  and 
the  longer  its  duration.  Death  seldom  occurs.  In 
every  case  where  I  have  seen  such  a  result  it  has  seemed 
to  me  that  there  was  organic  cerebral  disease  which 
caused  the  choreic  symptoms  and  the  fatal  termination. 

Treatment. — The  most  active  and  meddlesome 
treatment  has  been  advocated  by  some,  and  entire  ab- 
stinence from  medicine  by  others.  In  reality,  mild 
cases  probably  do  well  without  drugs. 

Hygienic  and  moral  treatment  is  necessary  in  every 
case.  The  child  should  be  noticed  as  little  as  possible  ; 
its  attention  not  called  to  its  infirmity,  unless  it  can  be 
praised  for  improvement.  Nothing  more  should  be  de- 
manded of  the  child  than  can  be  possibly  helped  ;  the 
desires  and  wants  of  the  child  should  be  anticipated, 
and  gratified  as  far  as  may  be  without  over-indulgence. 

22 


338  UNCLASSIFIED. 

Of  course,  tlie  child  should  be  taken  out  of  school,  and, 
if  necessary,  removed  from  the  society  of  playmates 
and  the  care  of  servants,  who  may  irritate  and  annoy 
it  by  reference  to  its  irregular  movements.  Common 
sense  and  knowledge  of  child  nature  will  serve  better 
than  any  written  directions  to  guide  this  part  of  the 
treatment.  Except  in  the  severer  cases,  confinement 
to  the  bed  and  house  is  unnecessary. 

Arsenic  has  proved  a  most  successful  medicine.  This 
should  be  given  at  first  in  moderate  doses,  then  the 
dose  rapidly  increased  to  the  limit  of  toleration.  Thus, 
beginning  with  three  or  four  drops  of  Fowler's  solution 
three  times  a  day,  the  dose  may  be  increased,  by  one 
drop  every  second  or  third  day,  until  the  child  takes 
twelve  or  fifteen  drops,  or  even  more,  at  a  dose.  This 
remedy  is  to  be  thus  continued,  increasing  the  dose 
until  either  nausea  follows  or  oedema  below  the  eyes 
shows  the  approach  of  toxical  effects.  If  nausea  re- 
quires the  drug  to  be  discontinued,  it  should  be  re- 
sumed in  the  same  dose  as  when  omitted  so  soon  as  the 
nausea  ceases.  Unless  given  in  large  doses,  no  benefit 
can  be  expected.  Many  times  it  is  of  benefit  to  use 
iron  also,  and  other  tonics.  Sulphate  of  zinc,  in  doses 
of  three  to  five  grains  three  times  a  day,  has  also  been 
highly  recommended.  I  have  generally,  however, 
found  the  arsenic  sufiicient. 

In  severe  cases,  where  the  spasmodic  action  inter- 
feres with  sleep,  it  may  be  necessary  to  give  remedies 
to  procure  the  needed  rest.  Of  these,  chloral  is  much 
the  best.  Perhaps  paraldehyde  would  be  as  service- 
able. It  is  not  desirable  to  give  opium,  or  any  of  its 
preparations,  if  it  can  be  avoided.  Hyoscyamus,  coni- 
um,  and  belladonna  may  be  used  as  occasion  requires. 
Calabar-bean  has  been  used  by  Bouchut ;  he  employed 
■003  to  '005  grm.  three  or  four  times  a  day  subcutane- 
ously,  with  benefit  to  the  patient.  In  many  cases  re- 
lief follows  the  application  of  ether  spray  to  the  back ; 
or  ice  along  the  spine  may  be  used  instead  of  the  ether. 


CHAPTER  XXIX. 

PAEALYSIS   AGITAIIS. 

LUYS  J.,  Contribution  a  Tetude  anatomo-pathologique  de  la 
paralysie  agitante.  Vencephale,  1882. — Berger,  Ueber  Paralysis 
Agitans.  Schmidt's  Jahrb.,  195, 1882,  p.  246.— Buzzard,  A  Clini- 
cal Lecture  on  Shaking  Palsy.  Brain,  Jan.,  1882,  p.  473.— Erlen- 
meyer,  a.,  Beitrag  zur  symptomatiscben  Behandlung  der  Pa- 
ralysis Agitans.  Cbl.  f.  Nervenheilkunde,  Psych.,  etc.,  May  1, 
1883,  p.  193. 

PARALYSIS  AGITANS.— SHAKING    PALSY.— PARKINSON'S    DISEASE. 

Paralysis  agitans  is  most  common  in  old  age,  the 
name  very  well  expressing  its  cliaracter — a  tremor,  more 
or  less  severe,  attended  with,  a  weakness  of  the  mnscles, 
and  a  certain  degree  of  stiffness.  Violent  emotions 
have  sometimes  been  thought  to  be  the  cause  ;  but  it  is 
very  doubtful  whether  such  is  the  case.  Otherwise  we 
know  nothing  as  to  its  aetiology. 

Symptoms. — The  tremor  is  peculiar  and  character- 
istic, showing  itself  when  the  limbs  are  at  rest,  dimin- 
ishing or  ceasing  during  voluntary  motion,  in  this  re- 
spect contrasting  strongly  with  the  tremor  of  sclerosis. 
The  temperature  is  not  increased,  although  there  is 
such  constant  muscular  action.  Occasionally  the  trem- 
bling entirely  ceases  just  before  death. 

In  the  early  stages  of  the  disease  the  tremor  is  very 
slight,  and  is  usually  confined  to  the  hands  and  fin- 
gers, often  to  the  thumb  and  index-finger,  which  are 
rapidly  adducted  and  abducted.  At  first  this  is  a 
slight  annoyance  to  the  patient,  and  does  not  interfere 
seriously  with  his  comfort  or  his  ordinary  pursuits. 
As  the  disease  advances,  however,  the  tremor  aifects 


340  UNCLASSIFIED. 

otlier  muscles,  becomes  more  marked,  and  greatly  an- 
noys the  patient.  It  does  not  cease  entirely  during 
voluntary  motion  of  the  parts,  and  so  may  interfere 
more  or  less  seriously  with  the  use  of  the  hands. 

Opinions  differ  somewhat  as  to  whether  the  head  is 
affected ;  it  certainly  is  in  some  cases. 

After  a  while,  to  the  tremor  is  added  a  weakness  of 
the  muscles — partial  paralysis.  There  is  also  stiffness 
of  the  joints,  the  hands  take  a  peculiar  position,  the 
thumb  and  index-finger  being  approximated,  as  if  hold- 
ing a  pen,  and  occasionally  there  is  a  slight  claw-shape 
position  of  the  fingers. 

The  electrical  reaction  of  the  muscles  is  normal. 

In  walking,  the  patient's  head  and  body  are  bent 
forward,  so  that  it  seems  almost  as  if  he  would  fall 
upon  his  face.  Instead  of  walking  naturally,  the  pa- 
tient trots  forward  with  short  steps,  as  if  the  position 
of  the  body  produced  a  sensation  of  falling,  and  he 
found  it  necessary  to  run  in  order  not  to  pitch  on  his 
face.  Sometimes  there  is  compulsory  motion  back- 
ward instead  of  forward.  The  tendon  reflexes  have 
been  noticed  to  be  exaggerated  in  both  the  upper  and 
lower  extremities.  Sensation  is  variously  modified  in 
some  cases,  and,  when  the  disease  is  advanced,  the 
mental  powers  suffer.  There  is  sleeplessness  and  loss 
of  memory,  sometimes  melancholia. 

Pathological  Anatomy. — No  satisfactory  explana- 
tion of  this  disease  has  been  proposed.  Many  careful 
autopsies  show  no  change  at  all  of  the  nervous  system, 
and  the  pathological  changes,  if  any,  remain  to  be  dis- 
covered, though  there  is  a  tendency  among  authors  to 
refer  the  disease  to  some  disturbance  of  the  medulla 
oblongata. 

DiAGisrosis. — The  diagnosis  must  be  made  from  scle- 
rosis of  the  nerve- centers,  with  which  this  disease  was 
formerly  confounded.  The  difference  in  the  character 
of  the  tremor,  the  positions  of  the  hands  in  an  ad- 
vanced case,  are  sufficient  to  distinguish  the  two.     The 


PARALYSIS  AGITANS.  341 

progress  of  the  disease  is  also  different.  The  cerebral 
symptoms  are  similar  in  only  a  few  cases.  They  occur 
earlier  in  sclerosis  than  in  paralysis  agitans. 

The  tremor  of  metallic  poisoning,  or  of  acholismus, 
may  be  diagnosticated  by  the  history  of  the  patient 
and  by  the  progress  of  the  disease. 

It  is  scarcely  possible  that  post-hemiplegic  chorea 
should  be  mistaken  for  paralysis  agitans  if  the  phy- 
sician is  sufficiently  careful. 

Peogistosis. — Recovery  is  not  to  be  expected.  In- 
termissions may  occur,  but  the  course  of  the  disease  is 
generally  forward. 

Teeatment.  — Very  little  can  be  said  in  regard  to 
treatment.  Some  few  drugs  are  of  value  as  long  as 
they  are  used ;  but  when  given  up,  the  tremor  returns. 
Erlenmeyer  found  that  chloral  produced  sleep,  but  had 
no  influence  upon  the  tremor.  An  infusion  of  valerian 
with  bromide  of  potassium  had  a  marked  effect  upon 
the  tremor  so  long  as  it  was  used.  Atropia  always 
diminished  the  tremor,  but  he  found  it  necessary  to 
omit  the  drug  on  account  of  a  slight  toxic  effect. 

Curare,  when  given  subcutaneously  in  a  dose  of 
0*033  of  a  gramme,  caused  the  tremor  to  diminish.  This 
improvement  continued  about  three  days. 

Eulenberg  recommends  very  highly  the  subcutane- 
ous injection  of  arsenic.  He  uses  Fowler's  solution 
diluted  with  two  parts  of  distilled  water,  giving  six  to 
ten  minims  for  a  dose.  These  injections  were  continued 
daily,  without  unpleasant  symptoms.  In  one  case, 
fifteen  injections,  in  another  four,  produced  a  very 
marked  diminution  of  the  tremor,  lasting  two  months. 

Hyoscyamia  has  been  recommended,  but  Erlen- 
meyer found  that  it  had  no  effect  unless  given  in  toxic 
doses. 

The  galvanic  current  may  give  relief,  applying  it  to 
the  head  and  neck  ;  but  when  the  treatment  is  discon- 
tinued, the  tremor  returns.  Static  electricity  has  also 
been  used  with  temporary  benefit. 


CHAPTER  XXX. 

EPILEPSY. 

EcHEVERKiA,  M.  Gr.,  On  Epilepsy.  New  York,  1870.— Ben- 
nett, A.  H.,  Analysis  of  100  Cases  of  E,  Brit.  Med.  Jour.,  March 
22,  1879,  p.  419.— Jackson,  J.  H.,  Lectures  on  the  Diagnosis  of  E. 
Med.  Times  and  Gaz.,  Jan.  11,  1879,  p.  29.— MacDonald,  C.  F., 
Feigned  E.  Am.  Jour,  of  Insanity,  July,  1880 ;  Boston  Med.  and 
Surg.  Jour.,  Dec.  30,  1880.— West,  J.  F.,  On  Trephining  for 
Traumatic  E.  Trans.  Med.-Chir.  Soc,  1880,  p.  23.— Seguin,  E. 
C,  Importance  of  the  Early  Recognition  of  E.  Med.  Record, 
Aug.  6,  1881. — Lunier,  Des  epileptiques  ;  des  moyens  de  traite- 
ment,  etc.  Annates  medpsycholog.,  March.,  1881,  p.  217. — Gow- 
ERS,  W.  R.,  Epilepsy,  London,  1881. — Marie,  P.,  Note  sur  I'etat 
de  la  pupille  chez  les  epileptiques.  Arch,  de  nevrol.,  iv,  1882,  p. 
42. — Beevor,  C.  E.,  On  Knee- Jerk,  etc.,  in  E.  Brain,  April,  1882, 
p.  56. — Alexander,  W.,  The  Treatment  of  E.  by  Ligature  of  the 
Vertebral  Arteries.  Brain,  July,  1882,  p.  170.— Russell,  J.,  The 
Remedies  in  the  Treatment  of  E.  before  the  Introduction  of  the 
Bromides.  Practitioner,  Feb.,  1883,  p.  81. — ^Weiss,  J.,  Ueber  EL 
und  deren  Behandlung.  Wiener  KliniTc,  April,  1884. — ^Ralfe, 
C.  H.,  Seventeen  Cases  of  E.  treated  with  Sodium  Nitrite.  Brit. 
Med.  Jour.,  Dec.  2,  1882,  p.  1095.— Walsam,  W.  J.,  On  Trephin- 
ing the  Skull  in  Traumatic  Epilepsy.  St.  Barth.  Hosp.  Rep., 
1883,  p.  127. 

Epilepsy  is  a  name  given  to  an  affection  whose  cMef 
characteristics  are  attacks,  recurring  with  more  or  less 
regularity,  in  which  the  patient  partially  or  entirely 
loses  consciousness,  and  is  generally  more  or  less  con- 
vulsed, there  being  no  organic  disease  to  which  these 
convulsions  can  be  referred  as  a  cause. 

Symptoms. — In  about  half  the  patients  there  is  a 
warning  aura,  indicating  the  near  approach  of  a  con- 
vulsion.   This  aura  may  consist  in  an  involuntary  mo- 


EPILEPSY.  343 

tion,  or  a  sensation  in  any  part  of  the  body  or  limbs, 
most  frequently  in  tlie  stomach ;  occasionally  it  is  a 
sound,  a  sight,  an  odor,  or  it  may  be  a  confused  mental 
action  ;  it  precedes  the  attack  a  few  seconds  or  minutes 
only. 

The  attack  may  begin  by  a  peculiar  shrill  cry,  upon 
which  the  patient  suddenly  drops  unconscious ;  or, 
without  this,  consciousness  is  lost,  and  the  patient  falls, 
perhaps  injuring  himself.  If  the  aura  has  given  suflS.- 
cient  warning,  he  may  be  able  to  sit  or  lie  down  before 
the  attack. 

In  a  very  large  proportion  of  cases  the  countenance 
changes,  the  face  becomes  pale,  the  eyes  have  a  pe- 
culiar vacant  look ;  tonic  spasms  seize  the  limbs  and 
body ;  the  patient  stiffens.  The  attack  may  begin  in 
one  limb  and  extend  to  the  whole  body,  or  it  may  be 
unilateral  or  bilateral  throughout.  During  the  tonic 
stage  the  limbs,  face,  and  head  may  be  drawn  into  un- 
natural positions ;  there  is  frequently  conjugate  devi- 
ation of  the  eyes,  with  rotation  of  the  head  to  one  side. 

After  a  few  seconds  or  minutes  clonic  spasms  gradu- 
ally take  the  place  of  the  tonic  rigidity ;  the  limbs  are 
jerked  about,  the  muscles  of  the  face  and  mouth  are 
affected,  there  is  frothing  at  the  mouth,  the  tongue 
may  be  bitten.  The  patient  is  not  tossed  about  much, 
as  occurs  in  hystero-epilepsy. 

The  countenance  changes  from  pale  to  livid  through 
venous  congestion.  The  pupils  are  dilated,  and  do  not 
react  to  light.  There  is  conjugate  deviation  of  the 
eyes,  with  rotation  of  the  head  to  the  opposite  side 
from  what  it  was  during  the  tonic  stage. 

Cutaneous  reflexes,  even  of  the  conjunctiva,  are 
abolished  during  the  attack. 

The  urine  may  be  voided  involuntarily,  especially 
during  nocturnal  fits  ;  the  fseces  are  less  commonly 
passed  during  the  attack.  The  spasms  gradually  de- 
crease in  frequency ;  the  intervals  between  the  contrac- 
tions are  longer  and  longer,  until  there  is  quiet. 


344  UNCLASSIFIED, 

Immediately  after  tlie  clonic  stage,  before  return  of 
consciousness,  the  patellar  tendon  reflex  is  increased, 
and  ankle  clonus  is  present  in  rather  more  than  half  the 
cases  ;  the  tendon  reflex  is  occasionally  abolished.  Dur- 
ing this  period  the  pupils  may  oscillate,  the  eyes  roU  in 
unison  from  side  to  side. 

After  lying  quiet  for  a  few  minutes,  the  patient 
gradually  comes  to  himself,  being  confused  for  a  while. 
Often  a  heavy  sensation  in  the  head,  or  headache,  suc- 
ceeds the  attack,  continuing  a  few  hours  or  days.  Some- 
times unilateral  paralysis,  or  weakness,  is  noticed  af- 
terward, and  may  persist  several  days.  Unilateral 
anaesthesia  after  the  spasm  is  probably  found  only  in 
hystero-epilepsy. 

Many  patients  faU  asleep  immediately  after  the  at- 
tack, sometimes  before  recovery  of  consciousness.  This 
is  scarcely  natural  sleep  ;  it  rather  resembles  stupor.  If 
the  fit  occurs  during  sleep,  the  patient  may  not  awake, 
and  in  the  morning  be  entirely  unaware  of  what  has 
occurred.  Others  will  recover  full  possession,  of  their 
faculties  as  suddenly  as  they  lost  them,  without  the 
least  discomfort  in  the  head  or  elsewhere.  Sometimes 
the  pulse  is  abnormally  slow  for  several  days,  or  even 
weeks,  after  the  attack. 

In  the  full,  complete  attack  of  epilepsy,  the  loss  of 
consciousness  is  absolute  and  entire. 

Attacks  may  be  much  less  severe  than  those  just 
described,  consisting  simply  of  a  momentary  loss  of 
consciousness,  without  spasm  of  any  kind ;  or  they 
may  be  reduced  to  the  aura,  consciousness  not  being 
interrupted,  though  mental  activity  and  ability  are  un- 
doubtedly somewhat  impaired.  These  attacks  without 
convulsions  are  called  petit  mal ;  those  with  convul- 
sions, grand  mal.  Every  grade  of  severity  is  found, 
from  the  slightest  ephemeral  sensation  to  the  severest 
convulsive  attack. 

Many  authors  consider  loss  of  consciousness  neces- 
sary to  constitute  epilepsy.     Nothnagel  is  right,  how- 


EPILEPSY.  345 

ever,  in  saying  that  complete  abolition  of  conscious- 
ness is  not  necessary  to  characterize  the  disease  as  epi- 
leiDsy,  "  but  that  simple  dizziness  is  sufficient ;  in  fact, 
any  alteration  whatever  of  the  mental  activity  occur- 
ring paroxysmally,  such  as  hallucinations  and  the 
like." 

Various  unusual  and  exceptional  manifestations  of 
epilepsy  deserve  mention.  Occasionally  during  the  at- 
tack patients  will  perform  acts  which  it  would  seem 
must  be  voluntary  and  conscious.  In  these  the  patient 
may  simply  perform  some  inoffensive  act,  as  walking 
rapidly  to  a  distance,  or,  as  in  one  of  my  patients,  a 
workman  began  to  gather  together  pieces  of  wood,  as 
if  to  carry  home  ;  or  the  acts  may  involve  more  serious 
consequences,  as  pocketing  various  articles  not  belong- 
ing to  himself,  or  making  an  attack  upon  by-standers, 
and,  if  the  impulse  is  strong,  the  patient  may  be  thrown 
into  a  frenzy,  and  may  commit  homicide.  After  these 
acts  there  is  no  recollection  of  what  has  been  done  dur- 
ing the  attack ;  there  may  be  the  same  oppression  in 
the  head,  and  even  the  same  tendency  to  sleep  as  after 
other  attacks.  Occasionally  the  patient  seems  to  see 
objects  which  do  not  really  exist ;  there  are  hallucina- 
tions of  sight. 

These  unusual  forms  of  epileptic  seizures  may  co- 
exist in  the  same  individual  with  the  more  common,  or 
may  precede  the  outbreak  of  the  latter  by  several 
months  or  years,  or  may  follow  after  a  course  of  reme- 
dial treatment. 

The  attacks  vary  greatly  in  frequency ;  they  may 
be  separated  by  an  interval  of  months,  or  even  years. 
The  earlier  attacks  occur  usually  at  mnch  longer  inter- 
vals than  the  subsequent,  when  the  disease  is  left  to 
run  its  course  without  treatment.  The  attacks  may 
occur  many  times  a  day.  H.  Hayes  Newington  reports 
("  Journal  of  Mental  Sciences,"  April,  1877,  p.  89)  a  case 
in  which  there  were  six  hundred  and  twenty-two  true 
epileptic  fits  in  twenty-four  hours.     This  great  number 


346  UNCLASSIFIED. 

was  excessive  and  unusual.  Of  ten  from  three  or  four 
to  ten  or  a  dozen  may  occur  in  the  course  of  the  day. 
It  is  very  common  to  have  the  attacks  recur  in  groups, 
several  within  a  few  hours  or .  days  ;  then  there  is  an 
interval  of  variable  length  free  from  attacks,  and  again 
a  series  of  several  in  rapid  succession. 

Epileptic  fits  may  take  place  either  during  the  day 
or  in  the  night ;  a  large  proportion  occur  in  the  early 
morning  hours,  just  before  or  Just  after  waking.  It  is 
impossible  to  estimate  exactly  the  proportion  of  cases 
occurring  during  the  night,  as  patients  are  often  entirely 
ignorant  of  having  had  an  attack.  If  one  wakes  with 
tongue  bitten,  bedclothes  stained  with  blood  and  in 
much  disorder,  if  the  bed  is  wet,  and  there  is  discom- 
fort in  the  head  in  the  morning,  it  is  more  than  likely 
that  there  has  been  an  attack.  Any  one  of  the  circum- 
stances should  give  rise  to  suspicion  in  the  case  of  an 
adult.  After  the  attacks,  small  subcutaneous  haemor- 
rhages may  be  seen,  especially  about  the  eyes  and  the 
rest  of  the  face.    These  disappear  in  a  few  days. 

The  patient's  limbs,  and  even  his  life,  are  not  safe  so 
long  as  he  has  the  attacks.  The  fact  of  being  in  a  po- 
sition of  iminent  danger  sometimes  seems  to  prevent 
the  occurrence  of  the  fit ;  thus  workmen,  whose  duty 
it  is  to  ascend  ladders  or  be  on  stagings,  will  sometimes 
be  entirely  free  from  fits  in  these  exposed  situations. 
It  is,  however,  never  safe  to  trust  to  such  exemj)tion. 
Epileptics  suffer  many  times  from  bruises,  and  even 
from  fractures  or  dislocations,  as  the  effects  of  their  at- 
tacks. They  may  also  fall  into  the  fire  and  receive 
severe  burns. 

Death  does  not  often  occur  during  the  fit.  Some- 
times, however,  cerebral  haemorrhage  is  the  direct  re- 
sult of  an  attack.  Occasionally  the  attacks  recur  with 
great  rapidity,  with  scarcely  a  perceptible  intermission  ; 
the  patient  is  in  a  state  of  epilepsy,  status  epilepticus, 
as  it  has  been  called,  in  which  the  fatal  termination 
may  occur. 


EPILEPSY.  347 

Between  tlie  attacks  the  patient  may  enjoy  the  most 
perfect  health,  and  if  the  attacks  are  nocturnal,  or  occur 
in  the  early  morning,  he  may  be  able  to  attend  to  all 
the  duties  of  life — may  even  manage  a  large  business 
without  any  one  suspecting  his  infirmity.  On  the  other 
hand,  it  is  possible  that  the  affection  may  lead  to  an 
impairment  of  mental  powers,  the  memory  at  first  be- 
ing weakened,  finally  imbecility  or  dementia  closing 
the  scene.  This  is  more  common  when  the  disease  be- 
gins in  early  life.  A  few  rarely  occurring  very  severe 
attacks  have  generally  little  influence  upon  the  mental 
powers  ;  frequently  recurring  petit  mal,  giving  friends 
much  less  concern,  may  more  seriously  undermine  the 
intellect. 

The  paralysis,  which  occasionally  appears  after  the 
attack  as  an  ephemeral  symptom,  may  become  perma- 
nent, continuing  from  one  attack  to  the  next.  In  such 
cases  it  is  probable  there  is  some  organic  cerebral  le- 
sion. 

Etiology. — Among  those  causes  which  give  rise  to 
a  state  of  the  nervous  system  predisposing  to  epilepsy 
may  be  mentioned  heredity  ;  not  that  the  ancestors 
have  necessarily  had  fully  developed  epilepsy ;  they 
may  have  shown  only  oddities  of  character,  or  mental 
extravagances,  or  they  may  have  suffered  from  neural- 
gia or  other  neuroses.  Parents  addicted  to  the  exces- 
sive use  of  alcoholic  drinks  may  transmit  to  offspring  a 
tendency  to  epilepsy. 

The  frequency  with  which  hereditary  influence  can 
be  shown  to  exist  in  this  affection— eighty  times  in  three 
hundred  and  six,  according  to  Echeverria — should  lead 
to  caution  in  regard  to  the  marriage  of  epileptics. 

The  excessive  use  of  alcoholic  drinks  may  develop 
a  tendency  to  epilepsy  in  the  subject ;  such  indulgence 
may  also  be  the  direct  cause  of  the  attacks.  Some  epi- 
leptics have  the  attacks  only  after  a  course  of  rather 
hard  drinking. 

The  period  of  puberty  is  that  in  which  the  disease 


348  UNCLASSIFIED. 

is  most  likely  to  be  developed  ;  much,  the  larger  num- 
ber of  cases  begin  between  ten  and  twenty-five  years  of 
age,  or  even  between  ten  and  twenty. 

Severe  and  prolonged  convulsions  in  infancy  are 
very  frequently  followed  by  epilepsy  later  in  life.  Ap- 
parently the  cause  of  the  earlier  convulsions  leads  to 
changes  in  the  brain,  which  favors  their  subsequent  re- 
turn. 

Various  depressing  agents  may  be  classed  as  pre- 
disposing causes,  as  worry,  anxiety,  grief,  or  excessive 
mental  work ;  but  it  is  quite  likely  that  many  times 
there  has  been  in  these  cases  a  predisposition  to  the 
disease  in  addition  to  the  above  depressing  agents. 

Syphilis,  especially  if  the  bones  of  the  skull  are  dis- 
eased, may  be  a  cause  of  epilepsy. 

Disease  of  the  bones,  induced  by  injuries  or  by 
other  causes  than  syphilis,  may  also  give  rise  to  at- 
tacks. 

The  causes  which  may  be  more  properly  called  ex- 
citing causes  are  blows  or  falls  upon  the  head,  whether 
giving  rise  to  fracture  of  the  skull  or  not,  injuries  to 
peripheral  nerves,  sunstroke,  fright,  anger  or  other  vio- 
lent emotion,  and  lead-poisoning. 

Phimosis  may  be  the  cause  of  such  an  irritation  as 
to  give  rise  to  epilepsy ;  it  would  seem  to  be  a  pre- 
disposing cause,  as  giving  rise  to  such  a  state  of  the 
system  as  to  favor  the  occurrence  of  epilepsy,  and  it 
also  may  alone  excite  the  attacks.  The  same  reflex  in- 
fluence may  depend  upon  other  sources  of  irritation,  as 
that  caused  by  teeth  cutting  through  the  gums. 

Occasionally  serious  disorders  of  digestion  or  im- 
prudence in  diet  seems  to  give  rise  to  the  attacks. 

At  the  best,  however,  it  is  often  impossible  to  dis- 
cover the  causes  which  lead  to  the  development  of  the 
tendency,  or  give  rise  to  the  fits. 

Brown-Sequard  found  that  after  certain  lesions  of 
the  nervous  system,  especially  in  Guinea-pigs,  a  por- 
tion of  the  face  suffered  a  change  in  its  nutrition  such 


EPILEPSY.  349 

that  irritation  of  the  cheek  would  excite  an  epileptic 
attack  ;  such  Guinea-pigs  might  transmit  the  tendency 
to  epilepsy  to  their  offspring.  Several  times  a  similar 
epileptogenous  zone  has  been  found  in  epile^Dtic  pa- 
tients. Otto  reports  a  case  of  a  patient  the  snapping 
of  whose  hat-elastic  caused  an  attack. 

DiAGJsrosis. — The  diagnosis  of  epilepsy  from  hysteria 
and  hystero-epilepsy  will  be  more  clear  after  their  de- 
scription in  the  next  chapter. 

The  lighter  attacks,  the  petit  mal,  may  be  recog- 
nized from  common  fainting  or  vertigo,  by  the  regu- 
larity or  frequency  of  their  recurrence,  by  the  brevity 
of  the  attack  in  epilepsy,  by  the  occasional  presence  of 
an  aura,  by  the  occurrence  of  the  grand  mal  at  long  in- 
tervals. 

The  possibility  of  vertigo  due  to  Meniere's  disease, 
or  the  lithemic  vertigo,  should  be  kept  in  mind. 

Criminals  and  others  try  to  simulate  epilepsy  to  es- 
cape punishment  or  gain  profit.  A  well-trained  impos- 
tor is  not  easily  discovered.  The  pallor  of  the  face, 
the  dilated  pupils,  reacting  suddenly  to  light,  can  not 
be  counterfeited,  and  it  is  scarcely  probable  that  the 
cornea  would  be  insensible  to  touch.  A  careful  watch- 
ing of  all  the  symptoms  would  lead  to  detection  of 
impostors,  unless  they  were  remarkably  well  trained. 
(See  MacDonald's  case.) 

PRoais'osis. — Most  patients  with  epilepsy  are  capa- 
ble of  improvement ;  few  can  be  expected  to  recover. 
The  earlier  in  life  the  attacks  begin,  and  the  longer 
they  have  persisted,  the  less  favorable  is  the  prospect. 

If  a  definite  cause  can  be  discovered,  as  teething, 
sunstroke,  lead-poisoning,  syphilis,  etc.,  the  chances 
are  in  favor  of  recovery  in  proportion  to  the  readiness 
with  which  these  causes  can  be  removed,  if  the  disease 
has  not  been  of  too  long  duration. 

Mental  failure  is  rare  when  the  attacks  begin  after 
puberty,  except  in  syphilitic  cases ;  when  they  com- 
mence early  in  life,  the  mind  is  much  more  likely  to  fail. 


350  UNCLASSIFIED. 

Treatment. — If  any  source  of  periplieral  irritation 
can  be  discovered  wMch  may  act  as  cause  of  the  fits, 
that  should  be  removed,  as  cicatrices,  phimosis,  or  irri- 
tation of  gums  by  teeth.  If  fracture  of  skull  or  de- 
pression, fragments  should  be  removed  or  raised. 

The  remedy  which  has  been  found  most  useful  is 
the  bromides.  It  is  rather  a  matter  of  taste  as  to  which 
bromide  should  be  employed ;  the  potassic,  sodic,  calcic, 
and  lithic  salt  act  very  nearly  alike.  Sometimes  an 
idiosyncrasy  on  the  part  of  the  patient  wiU  be  a  guide 
in  the  choice. 

Gowers's  method  of  giving  the  bromides  is  somewhat 
different  from  the  ordinary  way,  and  is  of  value.  He 
gives  very  large  doses  at  the  beginning  of  treatment — 
two  or  three  drachms  every  second  or  third  morning, 
increases  the  dose  to  four  drachms  every  fourth  morn- 
ing, and  six  drachms  or  an  ounce  every  fifth  morning. 
These  large  doses  should  be  given  after  breakfast,  in  a 
tumblerful  of  water.  When  drowsiness  and  mental 
dullness  follow  during  the  rest  of  the  day,  he  does  not 
increase  the  dose.  More  than  an  ounce  is  rarely  borne. 
The  maximum  dose  should  be  reached  in  two  or  three 
weeks  and  repeated  three  or  four  times,  and  the  doses 
then  gradually  reduced  ;  the  whole  course  lasts  six  or 
seven  weeks.  Unless  the  attacks  cease  entirely  when  a 
dose  of  four  drachms  is  reached,  he  gives  up  the  effort 
to  cure  the  patient.  After  omitting  the  bromide  a 
week  or  two,  he  gives  it  again  regularly  in  smaller 
doses,  twenty  grains  or  more  three  times  a  day. 

The  usual  method  of  giving  bromide  is  to  give  a 
dose  three  times  a  day ;  usually  the  dose  is  too  small. 
It  is  necessary  to  begin  with  at  least  fifteen  or  twenty 
grains  three  times  a  day,  and  the  dose  should  be  in- 
creased rapidly  till  some  evidence  of  its  action  is  ob- 
tained. Patients  may  take  sixty  to  ninety  grains  of 
bromide  a  day  for  six  or  ten  years  without  injury. 

When  large  doses  are  given,  acne  appears  on  the 
face,  back,  etc.  ;  three  to  five  drops  of  Fowler's  solu- 


EPILEPSY.  351 

tion  with  eacli  dose  of  tlie  bromide  will  tend  to  prevent 
this.  In  very  large  doses  patients  sometimes  find  their 
legs  getting  weak,  or  lose  their  memory.  If  the  dose 
is  diminished  or  omitted  for  a  few  days,  these  symp- 
toms disappear.  In  excessive  doses,  delirium  and 
symptoms  resembling  meningitis  may  be  produced. 
Of  course,  this  ought  to  be  avoided. 

Iron,  cod-liver  oil,  and  quinine  may  be  given  to  ad- 
vantage with  the  bromides. 

Occasionally  the  bromides  seem  to  lose  their  bene- 
ficial effect,  or  the  patient  becomes  disgusted  with  the 
drug.  Ralfe  recommends  then  the  use  of  sodium  ni- 
trite, free  from  the  nitrate. 

Atropia  is  frequently  used,  either  with  the  bromide 
or  alone,  sometimes  with  benefit.  With  it,  or  the  ex- 
tract of  belladonna,  may  be  used  valerianate  or  oxide 
of  zinc,  and  extract  of  hyoscyamus. 

Digitalis  is  sometimes  combined  with  the  bromides. 

Kunze  ^  used  curare  subcutaneously,  in  0'03  gramme 
doses,  every  fifth  day  for  three  weeks,  then  waited  for 
the  next  attack,  and  repeated.  The  first  sign  of  toxic 
action  is  a  blurred  vision. 

Wildermuthf  gave,  with  bromide,  osmic  acid  0*002 
gramme  in  watery  solution  or  pill,  or  0*004  gramme 
potassic  osmate,  with  benefit  in  an  old,  obstinate  case 
when  bromides  alone  failed. 

During  an  attack  the  patient's  clothes  should  be 
loosened ;  he  should  be  prevented  from  injuring  himself 
if  the  clonic  convulsions  are  violent.  A  towel  rolled 
firmly  into  a  cone,  or  a  piece  of  cork  or  rubber,  should 
be  put  between  the  teeth,  to  prevent  biting  the  tongue. 

When  an  aura  gives  opportunity,  the  inhalation  of 
nitrite  of  amyl  may  cut  the  attack  short.  Patients 
sometimes  learn  that  by  firmly  seizing  the  limb  in 
which  the  aura  is  felt,  or  by  tightly  bandaging  it,  they 
can  arrest  the  fit. 

*  "Wien.  med.  Presse,"  Oct.  20,  1878. 
t  "Berl.  kl.  Wocheiisclir.,"  June  9,  1884. 


352  UNCLASSIFIED. 

In  the  status  epilepticus,  inlialation  of  nitrite  of 
amyl  sometimes  is  beneficial.  Gowers  finds  the  most 
good  from  repeated  doses  of  chloral,  morphia  subcu- 
taneously,  and  the  application  of  ice  to  the  spine. 

The  diet  should  be  simple  and  unstimulating.  It  is 
well  to  restrict  the  use  of  animal  food  to  a  small  amount 
once  a  day,  or  forbid  it  entirely.  This  diet  is  most 
valuable  with  young  patients. 


CHAPTER  XXXI. 

HYSTEEIA  AND  HYSTEEO-EPILEPST. 

RiCHTER,  Ueber  psychische  Therapie  motorisclier  Storungen 
der  Hysterie.  Berl.  M.  Wochenschr.,  June  14,  1880,  p.  341. — 
Mitchell,  J.  Weir,  Lectures  on  Diseases  of  the  Nervous  System, 
especially  in  Women.  Philadelphia,  1881. — Debove,  L'hysterie 
chez  I'homme.  Gaz.  des  hdp.,  Nov.  20,  1882,  p.  1070. — Huchard, 
H.,  Caractere,  mceurs,  etat  mental  des  hysteriques.  Arch,  de 
nevrol.,  iii,  1882,  p.  187. — Axenfeld,  Traite  des  nevroses.  Paris, 
1883. — Dujardin-Beaumetz,  On  the  Treatment  of  Hysteria.  Med. 
News,  Aug.  4,  1883,  p.  113. — Grasset,  The  Relations  of  Hysteria 
with  the  Scrofulous  and  the  Tuberculous  Diathesis.  Brain,  Jan., 
July,  1884. 

Richer,  P.,  Etudes  clinique  sur  I'hystero-epilepsie,  ougrande 
hysterie.  Paris,  1881.— Mills,  C  K.,  Hystero-Epilepsy.  Am. 
Jour.  Med.  Sci.,  Oct.,  1881,  p.  392.— Welponer,  E.,  Exstirpation 
beider  Ovarien  wegen  Hystero-Epilepsie,  Heilung.  Wien.  med. 
Wochenschr.,  No.  30,  1879.— Walton,  Gt.  L.,  Hysteria,  as  affected 
by  Removal  of  the  Ovaries.  Boston  Med.  and  Surg.  Jour. ,  June 
5,  1884,  p.  529.— Peckham,  Gr.,  Metallotherapy,  Theoretically  and 
Practically  Considered.  Archives  of  Med.,  Dec,  1883,  p.  283. — 
See,  also,  on  Metallotherapy,  Charcot,  Lancet,  1878,  i.— West- 
phal,  Berl.  M.  Woch.,  1878,  p.  441.— Wilks,  Brit.  Med.  Jour., 
July  20,  1878. 

HYSTERIA. 

Hysteria  is  often  described  as  a  functional  disease 
of  the  nervous  system ;  it  would  be  more  exact  to 
speak  of  it  as  a  diseased  or  abnormal  state  of  the  nerv- 
ous system,  revealing  itself  by  peculiarities  of  tempera- 
ment, of  thouglit,  action,  and  affection,  with,  occasional 
outbreaks  of  motor  or  emotional  disturbance. 

Formerly  the  convulsive  phenomena  were  considered 
as  essential ;  but,  while  their  importance  is  still  recog- 

23 


354  UNCLASSIFIED. 

nized,  more  attention  lias  been  recently  given  to  the 
state  of  the  nervous  system,  which  renders  these  phe- 
nomena possible. 

Etiology. — Briquet  says  half  the  women  have  a 
predisposition  to  hysteria — that  is,  they  are  very  im- 
pressionable. This  predisposition  is  also  seen  in  a  few 
men,  and  a  small  number  of  males  are  attacked. 

The  age  at  which  the  affection  is  most  common  lies 
between  puberty  and  twenty  years.  After  that  age 
there  is  a  gradual  diminution  in  the  proportion  of  pa- 
tients. Among  young  girls  Briquet  found  about  a 
quarter  or  a  fifth  as  many  cases  as  among  those  who 
had  commenced  to  menstruate.  There  are  many  cases 
reported  as  occurring  in  boys. 

Heredity  plays  an  important  part  in  predisposing  to 
hysteria.  It  will  often  be  found  that  some  form  of 
nervous  disturbance  is  prevalent  among  the  relations  of 
such  patients.  Huchard  says  that  in  hysterical  women 
it  will  be  found  thirty  times  in  one  hundred  cases  that 
the  parents  have  been  hysterical,  but  in  women  not 
thus  affected  only  four  times  in  one  hundred  cases  will 
this  be  found  to  be  the  case.  Briquet  found  that  a  little 
more  than  half  the  hysterical  mothers  had  transmitted 
the  affection  to  their  daughters. 

It  can  not  be  doubted  that  the  training  to  which 
young  girls  are  subjected  influences  the  predisposition 
to  hysteria ;  their  home  training  and  school  training, 
their  food,  exercise,  clothing,  the  amount  of  sleep  ob- 
tained, the  amusements  allowed,  the  self-restraint  which 
they  may  be  taught — these  and  many  other  conditions 
either  increase  their  natural  predisposition  or  dimin- 
ish it. 

And  not  only  do  children  show  the  effect  of  their 
mode  of  life  ;  older  women  show  it  also,  and  a  tendency 
to  hysteria  may  be  created,  or,  if  existing,  may  be 
neutralized,  by  the  surroundings  of  the  patient  and  by 
those  indulgences  which  she  allows  herseK,  or  by  those 
privations  to  which  she  may  of  necessity  be  exposed. 


HYSTERIA.  355 

Whatever  lowers  the  healthy  tone  of  the  system,  as  a 
whole,  may  serve  indirectly  as  a  cause  of  hysteria :  the 
depressing  passions,  care  and  worry,  disease  of  any  or- 
gans, but  more  especially  of  the  uterus  and  its  append- 
ages, may  give  rise  to  the  state  of  the  nervous  system 
which  favors  the  development  of  the  affection. 

Accidents  and  bodily  injuries  must  be  counted 
among  the  predisposing  causes  of  hysteria.  Those  ac- 
cidents which  are  accompanied  with  nervous  shock  and 
fright,  as  when  a  horse  runs  away  with  the  carriage  in 
which  the  patient  is  riding,  or  railroad  accidents,  are 
most  likely  to  give  rise  to  this  state  of  the  nervous  sys- 
tem. * 

Some  of  these  causes  which  act  as  predisposing  to 
hysteria  may  become  the  direct  cause  of  an  attack  in 
patients  who  are  otherwise  predisposed  thereto.  Imi- 
tation may  give  rise  directly  to  an  attack. 

Symptoms. — In  hysteria  there  is  found  a  perversion 
of  certain  faculties  and  characteristics  of  the  patients. 
There  is  a  paralysis  or  weakness  of  the  moral  sense  and 
of  the  will,  an  exaggeration  of  the  emotions  and  the  af- 
fective faculties,  vdth  irregular  and  perverted  action  of 
the  cutaneous,  visceral,  and  special  senses.  Nearly,  if 
not  quite,  all  the  phenomena  of  hysteria  can  be  ex- 
plained by  supposing  the  above  changes. 

The  special  manifestations  of  hysteria  in  different 
patients  are  almost  as  varied  as  are  the  diseases  to 
which  humanity  is  liable.  Even  in  ordinary  health 
these  patients  show  a  nervous  mobility,  a  habit  of  ex- 
aggeration, a  morbid  desire  for  sympathy,  an  excessive 
sensitiveness  and  ardent  imagination  which  is  charac- 
teristic. 

The  disturbance  of  the  moral  sense  may  show  itself 
simply  by  persistent  exaggeration  of  symptoms — an  ex- 
aggeration which  almost  amounts  to  simulation ;  or 
there  may  be  deliberately  planned  simulation.  The 
patient  will  pretend  to  have  symptoms  which  do  not 
exist ;  she  will  produce  haemorrhage  from  some  portion 


356  UNCLASSIFIED. 

of  tlie  moutTi,  and  pretend  to  have  haemoptysis ;  she 
will  pretend  to  vomit  urine  instead  of  secreting  it  by 
the  kidneys  ;  and  perhaps,  in  order  to  keep  up  the  illu- 
sion, she  will  drink  her  urine  immediately  after  passing 
it.  The  patient  may  pretend  that  she  is  paralyzed,  or 
is  so  weak  that  she  is  unable  to  rise ;  yet,  when  she 
thinks  herself  alone,  she  may  be  seen  to  rise  and  cross 
the  room. 

A  more  serious  and  important  exhibition  of  this 
propensity  for  lying  is  occasionally  met  in  hysterical 
women ;  they  will  accuse  a  physician  or  dentist  or 
priest  of  taking  improper  liberties  with  them,  or  of  vio- 
lating them.  The  records  of  legal  medicine  contain 
many  such  instances. 

The  foundation  for  some  of  the  complaints  of  the 
hysteric  may  be  a  real  discomfort ;  this  discomfort  or 
pain  is  exaggerated  by  the  patient.  A  slight  pain  in 
the  eyes,  when  open  to  the  light,  is  exaggerated  into 
severe  photophobia,  and  the  patient  must  remain  in  a 
dark  room  ;  yet  when  the  oculist  wishes  to  examine  the 
eyes  the  light  is  born  without  complaint,  and  even  the 
ophthalmoscope  can  be  used  without  the  patient's  com- 
plaining. A  slight  discomfort  in  swallowing  is  exag- 
gerated into  entire  loss  of  power  to  take  food,  and,  if  a 
sound  is  passed,  a  very  persistent  spasmodic  stricture 
may  be  found.  So  it  may  be  in  regard  to  other  symp- 
toms ;  but  it  will  often  be  very  difficult  to  judge  wheth- 
er there  is  any  foundation  at  all  for  the  pretended  ina- 
bility. 

The  disturbance  of  the  emotions  and  affections  is 
sometimes  very  marked  in  hysterics.  Huchard  thinks 
it  is  not  common  to  find  excessive  sexual  excitement  in 
hysterical  patients  ;  that  sexual  desire  may  be  entirely 
lost.  Other  passions  may  be  exaggerated  ;  they  easily 
acquire  a  repugnance  for  persons  ;  they  long  for  atten- 
tion and  manifestations  of  love  from  others.  This  pe- 
culiarity may  lead  to  the  simulation  of  disease  ;  but  in 
much  the  greater  proportion  of  hysterical  patients  it  is 


HYSTERIA.  357 

shown  only  by  a  claim  upon  tlie  attendants  or  members 
of  tbe  family  for  care  and  attention.  Self  is  elevated  to 
the  bighest  place  in  tbese  patients,  and  self  mnst  be 
served  first  and  always.  A  mother  may  exact  from  a 
daughter  constant  attendance,  even  at  the  price  of  ruin- 
ing that  daughter's  health  ;  a  daughter  may  be  Jealous 
of  brothers  and  sisters,  and  become  worse  whenever  the 
mother  tries  to  give  care  to  other  members  of  the 
family. 

Sometimes  the  patient  has  only  one  class  of  symp- 
toms ;  probably,  in  such  cases,  there  is  real  disease, 
pain,  or  discomfort,  as  a  foundation  for  her  complaints. 
At  other  times  the  complaints  and  symptoms  vary  from 
week  to  week,  or  in  different  attacks  ;  even  during  the 
physician's  visit  she  may  recite  a  long  list  of  ill- con- 
nected symptoms,  inconsistent  with  one  another, 

"  They  love  to  carry  everything  to  extremes,  do  not 
know  how  to  live  in  simplicity ;  they  exaggerate  all 
their  feelings,  indifference  as  well  as  enthusiasm,  affec- 
tion as  well  as  antipathy,  love  as  well  as  hate,  joy  as 
well  as  despaii^  and  they  dramatize  everything  on  the 
great  stage  of  the  world,  where  they  are,  and  always 
remain,  true  comedians." 

The  intellectual  condition  of  hysterics  is  generally 
unnatural.  They  are  not  able  to  turn  their  minds  to 
the  more  serious  occupations  in  which  they  may  have 
once  engaged  ;  those  who  have  been  familiar,  with  their 
mental  power  when  in  health  will  probably  find  that 
there  has  been  a  loss  therein.  Though  this  is  true  of 
the  higher  and  more  comxolicated  processes  of  thought, 
yet  in  the  ordinary  round  of  daily  life,  and  on  a  lower 
plane,  their  mental  activity  may  be  exaggerated,  their 
conversation  may  be  lively,  animated,  witty,  and  en- 
tertaining ;  they  may  appear  even  brighter  than  is 
natural,  perhaps  relapsing  soon  into  silence  and  indif- 
ference. 

The  special  senses,  particularly  hearing  and  smell, 
may  be  abnormally  acute  ;  occasionally  hallucinations 


358  UN0LAS8IFIED. 

of  sight,  hearing,  or  odor  may  be  noticed,  though  it  is 
necessary  to  guard  against  error  as  to  the  two  last 
senses,  the  patient  noticing  sounds  and  odors  which 
are  not  perceived  by  the  attendants.  Perversion  of 
taste  may  lead  to  a  distaste  for  certain  articles  of  diet, 
or  a  desire  for  abnormal  articles. 

Ordinary  sensation  may  be  diminished  or  increased 
in  acuteness ;  such  changes  are  more  frequent  in  the 
form  called  hystero-epilepsy  than  in  simple  hysteria, 
yet  even  this  will  show  at  times  abnormal  conditions  of 
sensation. 

Pain  may  be  felt  in  different  regions,  and,  as  has 
been  noticed,  the  acuteness  of  the  pain  may  be  much 
exaggerated  by  the  patient.  Headache  is  not  uncom- 
mon, and  backache  is  often  met  in  these  patients.  The 
pain  may  be  very  severe  just  l^elow  the  breast,  espe- 
cially on  the  left  side.  There  may  be  severe  pain  and 
tenderness  in  the  Joints,  simulating  arthritis.  It  would, 
however,  require  much  too  large  a  space  to  enumerate 
all  the  changes  of  this  nature  which  may  be  found  in 
hysterics. 

Sometimes  there  is  a  great  diminution  of  the  urinary 
secretion  ;  and  there  may  be  even  a  temporary  suppres- 
sion, which  has  been  known  to  extend  over  some  days. 
Charcot  reports  a  case,  observed  during  four  months, 
in  which  there  was  a  great  diminution  in  the  amount 
of  urine,  an  average  of  three  grammes  during  August ; 
on  several  occasions  there  was  total  suppression,  once 
for  eleven  days.  The  patient  vomited  much,  and  the 
vomitus  contained  urea. 

Among  other  abnormal  conditions  may  be  mentioned 
excessive  sweating,  disturbance  of  the  gastric  secre- 
tions, enormous  secretion  of  gas  in  the  stomach  and  in- 
testines. 

Paralysis  affecting  various  parts  of  the  motor  sys- 
tem is  sometimes  seen,  affecting  an  entire  limb,  or  only 
a  few  muscles.  Muscles  thus  affected  give  a  normal 
reaction  to  the  electric  cuiTent.    It  is  said  by  some  that 


HYSTEBIA.  359 

normal  response  to  the  motor  irritation,  with  loss  of 
sensitiveness  to  the  current,  is  diagnostic  of  hysterical 
paralysis.  If  the  anaesthesia  is  extreme,  and  the  reac- 
tion perfect,  this  may  be  an  aid  to  diagnosis,  but  it  is 
not  alone  sufficient  to  found  a  diagnosis  upon.  Instead 
of  total  paralysis,  there  may  be  contraction,  persisting 
for  months  or  years. 

Aphonia  may  be  hysterical  in  its  origin  ;  the  patient 
may  lose  her  voice  entirely,  and  be  obliged  to  have  re- 
course to  signs  to  make  herself  understood,  or  there 
may  be  an  ability  to  whisper.  This  hysterical  aphonia 
is  rather  intractable,  and  is  very  likely  to  recur. 

The  symptoms  above  noticed  may  appear  in  dis- 
tinct attacks,  between  which  the  constitutional  pecul- 
iarities are  still  to  be  noticed,  but  in  less  marked  de- 
gree. 

There  are  other  attacks,  attended  with  more  or  less 
violence,  which  are  more  generally  known  as  hysterical 
attacks.  These  crises  are  attended  with  spasmodic  ac- 
tion, or  with  excessive  emotional  disturbance ;  often 
begin  with  a  sensation  as  if  a  ball  rose  from  the  epi- 
gastrium to  the  throat  {globus  hystericus),  or  that  may 
be  the  whole  of  the  spasmodic  attack.  Then,  when 
this  sensation  has  reached  the  throat,  there  is  a  general 
spasm,  attended  with  screaming,  with  crying  and  sob- 
bing, mingled  with  wild  laughter.  Sometimes  this 
spasm  commences  suddenly,  without  the  preceding 
aura.  During  the  attack  the  patient  seems  to  be  un- 
conscious, yet  afterward  may  have  a  recollection  of 
most  that  occurred.  The  heart  may  beat  rapidly  and 
strongly  ;  the  respiration  is  accelerated  ;  the  patient, 
feeling  a  sense  of  suffocation,  may  clutch  at  her  throat, 
and  try  to  tear  her  clothing.  Muscular  movements  in 
these  attacks  are  generally  co-ordinated  to  accomplish 
some  purpose,  and  are  semi- voluntary,  or  entirely  un- 
der the  control  of  the  will,  though  that  wiU  may  be 
perverted.  These  attacks  last  from  a  few  minutes  to  a 
few  hours. 


360  UNCLASSIFIED. 

After  the  attack  tlie  patient  is  usually  exhausted, 
lies  still,  with  eyes  shut,  is  disinclined  to  speak,  and 
may  seem  more  than  half  ashamed.  Commonly  a  large 
amount  of  pale  urine,  of  low  specific  gravity,  is  voided 
soon  after  an  attack. 

HTSTERO-EPILEPST. 

Charcot  first,  and  later  his  pupils  and  others,  have 
given  descriptions  of  attacks  occurring  in  hysterical 
patients  which  seem  to  be  combinations  of  epilepsy 
and  hysteria.  Gowers,  indeed,  considers  these  to  be 
hysteria  added  to  and  occurring  after  epileptic  at- 
tacks. 

In  this  manifestation  of  disordered  nervous  action 
there  are  more  or  less  distinct  attacks,  with  periods  of 
remission,  or  rarely  intermission  of  symptoms. 

The  convulsive  attacks  never  occur  without  warn- 
ing. The  patient  shows  a  change  in  her  disposition, 
becoming  irritable,  moody,  gay  and  lively,  or  sad  and 
desponding.  She  may  be  quiet  or  restless ;  she  may  com- 
plain of  headache,  or  of  pain  elsewhere,  especially  in 
the  ovarian  region.  There  may  appear  also,  before  the 
fully  developed  attack,  the  hypersesthesia  and  the  an- 
aesthesia of  one  side  or  the  other,  as  is  seen  between 
the  convulsive  attacks.  These  prodromes,  especially 
the  psychical,  may  appear  even  several  days  before  the 
attack. 

The  attack  is  divided  by  Richer  and  others  into  four 
periods : 

1.  The  epUeptoid. 

2.  That  in  which  contortions  prevail. 

3.  Period  of  emotional  attitudes. 

4.  Period  of  delirium. 

The  epileptoid  period  is  immediately  preceded  by 
slight  convulsive  movements,  as  winking  the  eyelids 
with  extreme  frequency,  general  tremor,  and  rapid 
respiratory  movements ;  during  this  prodromic  stage 
consciousness  is  retained  ;  it  seems  sometimes  as  if  un- 


HYSTERO-EPILEPSY.  361 

usual  interest  in  the  i:)lienomena  hastens  the  advent  of 
the  convulsions,  during  which  consciousness  is  lost. 

The  fully  developed  epileptoid  attack  very  closely 
resembles  an  attack  of  true  epilepsy  ;  first  there  is  a 
rigidity  of  the  body  and  limbs,  with  a  slow  motion  of 
different  parts,  the  body  is  slowly  bent  back,  the  neck 
is  swollen,  or  the  head  slowly  turns  to  one  side.  The 
face  is  pale,  then  congested  ;  the  features  are  distorted  ; 
the  limbs  are  slowly  and  stiffly  moved,  usually  turned 
on  their  axis,  or  flexed  and  extended  ;  the  arms  assume 
the  position  of  extreme  pronation  ;  the  legs  are  strong- 
ly adducted  ;  the  feet  turned  inward  or  outward. 

This  is  followed  by  a  short  stage  of  rigidity,  with- 
out motion ;  the  patient  remains  immovable  in  the 
position  in  which  she  is  found  at  its  beginning ;  usual- 
ly the  body  is  extended,  in  dorsal  decubitus,  with  the 
head  bent  back  slightly,  the  arms  extended,  pronated  ; 
or  other  postures  may  be  assumed.  The  whole  dura- 
tion of  this  stage  may  be  a  minute. 

Next  follows  a  stage  of  clonic  convulsions  of  limited 
excursion,  sometimes  general,  sometimes  unilateral ; 
these  resemble  the  clonic  convulsions  of  epilepsy. 
Muscular  resolution  is  next  seen,  with  stertorous  res- 
piration, and  frothing  at  the  mouth.  The  clonic  stage 
lasts  about  a  minute  ;  that  of  muscular  resolution  a  few 
minutes. 

The  second  of  Richer' s  periods  may  be  divided  into 
that  of  illogical  attitudes  and  that  of  great  movements. 
In  the  first  of  these  the  patient  assumes  the  most 
varied,  extraordinary  postures  with  great  force,  ex- 
treme opisthotonus  being  the  position  most  frequently 
assumed. 

The  stage  of  great  movements  is  characterized  by 
rapid,  alternating  motions  of  flexion  and  extension  of 
the  body ;  the  limbs  may  also  be  moved  about.  At  the 
beginning  of  this  stage  the  patient  may  utter  a  pierc- 
ing cry,  or  she  may  strike  herself,  or  tear  her  hair  or 
clothing. 


362  UNCLASSIFIED. 

In  the  second  period  tlie  loss  of  conscionsness  is  not 
complete.  The  contortions  are  of  longer  duration  than 
the  epileptoid  spasms,  sometimes  five  or  ten  minutes ; 
there  is  no  foaming  at  the  mouth,  no  suspension  of  the 
respiration,  no  inspiratory  spasm,  and,  consequently, 
no  turgescence  of  the  face. 

The  tJiird  period  is  that  of  hallucinations.  The  pa- 
tient's words  and  gestures  are  in  harmony  with  her  hal- 
lucinations. General  and  special  sensibility  are  abol- 
ished. 

This  third  period  may  imperceptibly  merge  into  the 
fourth,  or  that  of  delirium,  in  which  the  patient  seems 
to  review  the  events  of  her  past  life.  With  this  the 
attack  may  cease,  the  patient  often  passing  a  large 
amount  of  pale,  clear  urine. 

Curious  and  important  phenomena  in  these  patients 
are  connected  with  the  effects  of  pressure  over  certain 
areas  of  the  body.  This  pressure  may  give  rise  to  an 
attack  ;  these  spots  differ  in  different  patients,  and 
sometimes  corresponding  spots  on  both  sides  of  the 
body  must  be  pressed.  These  regions  are  just  above 
the  breasts,  just  below  the  breasts,  under  the  axillae,  just 
over  the  crests  of  the  ilia,  between  the  scapulse,  and  over 
the  ovaries.  Immediately  after  an  attack,  pressure  over 
the  hysterogenic  zone  may  not  induce  another. 

Another  phenomenon  is  that  pressure  over  one  ova- 
ry— that  which  between  the  attacks  is  hypersesthetic — 
will  often  cause  the  attack  to  cease  immediately.  The 
patient,  though  violently  convulsed,  falls  on  the  bed 
entirely  relaxed,  and  may  soon  recover  consciousness  ; 
sometimes,  however,  another  attack  succeeds  before 
consciousness  is  fully  restored.  This  pressure  must  be 
directed  so  as  to  affect  the  ovary,  and  it  may  be  neces- 
sary to  use  great  force  to  obtain  the  result. 

When  the  hysterogenic  zone  is  not  in  the  ovarian 
region,  pressure  over  that  zoue  may  cause  the  attack  to 
cease,  or  it  may  cease  from  pressure  only  when  that  is 
exerted  over  the  ovary. 


EYSTER0-EPILEP8T.  363 

During  tlio  attack  the  eyes  are  anaesthetic,  even  dur- 
ing the  period  of  delirium,  and  the  cornea  may  be 
touched  without  exciting  reflex  movements  of  the  lids  ; 
sometimes  tears  will  flow  after  such  a  test,  and  some- 
times the  eye  remains  dry. 

The  variations  of  the  pupils  have  been  studied  late- 
ly by  Fere.  During  the  attack  the  pupils  are,  as  a  rule, 
only  slightly  influenced  by  the  light.  During  the  first 
part  of  the  first  period  the  pupils  remain  contracted ; 
immediately  at  the  commencement  of  the  second  part 
of  this  period,  when  the  clonic  spasms  set  in,  they  are 
widely  dilated,  and  remain  so  until  the  period  of  emo- 
tional attitudes ;  during  that,  and  the  period  of  deliri- 
um, the  pupils  contract  and  dilate  according  to  the 
nature  of  the  hallucinations,  whether  the  objects  pre- 
sented to  the  mind  seem  to  be  near  or  remote. 

Of  course,  in  imperfect  attacks,  all  these  phases  of 
the  pupils  may  not  be  seen.  Yet  Fere  noticed  in  one 
instance,  where  the  attack  consisted  only  of  the  great 
movements,  in  which  the  pupils  are  dilated,  that  before 
the  attack  the  pupils  contracted  with  great  energy, 
though  there  was  no  sign  of  other  contraction. 

The  condition  of  patients  between  the  attacks  is 
peculiar  and  interesting.  As  a  rule,  there  is  hemian- 
sesthesia,  affecting  the  side  opposite  the  tender  ovary, 
yet  there  are  exceptions  to  this  rule  where  the  loss  of 
sensibility  is  on  the  same  side.  The  side  which  is  not 
hemiansesthetic  is  in  a  state  of  hyperaesthesia. 

Not  only  is  there  loss  of  general  sensation,  of  touch, 
and  pain,  but  the  special  senses  are  affected  on  the 
same  side  with  the  general  sensibility  ;  sight,  hearing, 
smell,  and  taste  may  all  be  diminished  on  that  side. 

Fere  has  carefully  studied  the  condition  of  the  eyes 
in  these  patients.  He  finds  the  field  of  vision  limited, 
almost  reduced  to  nothing,  with  complete  loss  of  per- 
ception of  color.  In  such  patients  there  is  complete 
anaesthesia  of  the  conjunctiva  and  cornea ;  the  reflex 
action  of  pupil  and  lids  is  also  much  interfered  with. 


364  UNCLASSIFIED. 

In  other  patients  there  may  be  only  a  moderate  limita- 
tion of  the  field  of  vision,  and  partial  loss  of  perception 
of  color.  These  two  kinds  of  visual  defect  generally 
show  a  direct  relation  and  harmony  between  them- 
selves. Where  there  is  only  partial  loss  of  visual  pow- 
er, the  anaesthesia  of  the  eyeball  varies  according  to  the 
amount  of  visual  disturbance. 

Diagnosis. — Sometimes  the  general  physiognomy 
of  the  patient  reveals  to  the  physician  that  he  has  to 
do  with  a  hysterical  case ;  again,  the  singular  combi- 
nation of  symptoms  presented  is  sufficient  to  give  a 
clew  to  the  nature  of  the  affection. 

Where  there  are  no  convulsive  attacks,  when  the 
patient  imagines  disease  of  some  organ,  the  physical 
examination  of  that  organ,  and  a  comparison  of  the 
symptoms  with  those  which  ought  to  be  present,  will 
often  be  sufficient  for  a  diagnosis.  It  may  not  be  pos- 
sible to  arrive  at  a  conclusion  immediately,  but  careful 
observation  of  all  the  symptoms  will  generally  lead  to 
a  correct  diagnosis  within  a  few  days. 

When  the  hysterical  simulation  takes  the  appear- 
ance of  nervous  diseases,  it  may  not  be  easy  to  decide 
whether  there  is  real  disease.  If  the  history  of  the  pa- 
tient and  of  the  attack  can  be  obtained,  the  task  will 
be  less  difficult.  As  it  would  be  awkward,  to  say  the 
least,  to  treat  as  hysterical  a  patient  who  has  a  real  or- 
ganic lesion,  great  care  in  the  first  examination,  and 
careful  watching  of  changes,  is  essential.  If  the  pa- 
tient, by  inheritance,  age,  and  temperament,  seems  to 
be  predisposed  to  hysteria,  if  the  disease  can  be  re- 
ferred to  some  disturbing  emotion,  if  its  symptoms  are 
singular  and  in  striking  contrast  to  those  arising  from 
any  organic  lesion,  and  if  there  is  much  variation  from 
time  to  time  in  the  symptoms,  such  as  renders  the  exist- 
ence of  organic  disease  almost  impossible — if  these  con- 
ditions exist,  it  may  be  safe  to  diagnosticate  hysteria. 

The  diagnosis  of  the  convulsive  hysterical  attacks 
from  epilepsy  is  not  always  easy.    The  fully  developed 


HYSTERIA.  365 

attack  of  hystero-epilepsy  is  not  to  be  mistaken ;  but 
the  imperfect,  partial  attacks  may  not  be  at  once  rec- 
ognized. 

The  aura  is  not  the  same  ;  the  globus  Tiystericus  is 
rarely  met  in  true  epilepsy.  The  manner  in  which  the 
patient  tells  about  the  aura  will  sometimes  aid  in  form- 
ing an  opinion  as  to  the  nature  of  the  attacks.  The 
hysteric  almost  never  falls  suddenly,  as  the  epileptic  ; 
there  is  a  gradual  sinking,  and  ability  to  save  one's 
self  from  injury.  Except  in  hystero-epilepsy,  con- 
sciousness is  not  totally  abolished  in  hysteria ;  the  pa- 
tients will  remember  somewhat  of  the  events  during 
the  attack.  The  convulsions  last  longer  in  hysteria, 
and  are  more  varied  ;  they  are  also  of  wider  excursion  ; 
the  patients  throw  themselves  about  more.  As  the  at- 
tack ends,  its  hysterical  nature  is  sometimes  clearly  re- 
vealed by  the  sobbing  and  crying,  or  by  the  attack  of 
laughing  which  follows.  The  state  of  the  patient  be- 
tween the  attacks  will  be  an  important  aid  to  diagnosis. 
The  epileptic,  after  the  heaviness  and  dullness,  or  pa- 
ralysis, which  is  sometimes  seen  after  an  attack,  has 
passed,  is  as  well  as  ever,  and  shows  no  sign  of  disturb- 
ance, unless  the  disease  has  begun  to  affect  the  mind. 
The  hysteric  has  the  psychical  peculiarities  between  the 
attacks  which  have  been  previously  described.  If  a 
large  amount  of  pale  urine,  of  low  specific  gravity,  is 
passed  immediately  after  an  attack,  the  chances  are  de- 
cidedly in  favor  of  hysteria. 

Peogi^osis. — Life  is  not  in  any  special  danger  from 
hysteria.  When  once  the  predisposition  has  developed 
into  the  actual  hysterical  state,  recovery  is  at  best  a 
distant  possibility.  The  favorable  termination  will  de- 
pend upon  how  thoroughly  the  patient's  constitution 
has  been  undermined  by  early  education  and  trials,  and 
upon  how  much  can  be  done  to  restore  a  natural  vigor 
to  the  nervous  system. 

When  the  predisposition  is  slight,  or  absent,  treat- 
ment is  much  more  likely  to  be  successful. 


366  UNCLASSIFIED. 

Relapses  are  very  likely  to  occur ;  a  patient  may  be 
well  for  many  months,  until  some  excitement  or  emo- 
tion awakens  again  tke  symptoms. 

In  hystero-epilepsy  the  prospect  of  recovery  from 
the  earlier  attacks  is  the  more  favorable.  As  the  fre- 
quency of  the  attacks  increases,  the  prognosis  becomes 
more  grave. 

Treatment. — Treatment  should  begin  with  children 
of  neurotic  parents  about  as  soon  as  they  are  born,  to 
prevent,  if  possible,  the  development  of  the  hysterical 
predisposition.  Care  in  regard  to  the  child's  surround- 
ings, its  food,  exercise,  sleep,  study,  and  government, 
is  to  be  continued  throughout  childhood  and  youth. 
Sometimes  the  mother  is  not  suitable  to  look  after  the 
child,  and  the  care  must  be  given  to  others.  In  all 
such  cases  the  family  physician  has  it  in  his  power  to 
do  much  by  advice  and  warning.  Huchard  formulates 
this  line  of  treatment  thus :  "To  favor  the  physical  de- 
velopment at  the  expense  of  the  moral  and  intellectual 
development." 

After  the  disease  has  once  shown  itself,  it  will  be 
necessary  to  use  all  the  hygienic  means  at  one's  com- 
mand to  counteract  the  predisposition,  and  the  pa- 
tient's life  may  need  to  be  watched  and  regulated  for 
months  or  years.  Often  this  can  be  done  better  away 
from  home.  The  patient  is  self-willed,  and  needs  to  be 
under  control,  which  will  not  be  exercised  at  home. 

As  disease  of  one  of  the  viscera  may  be  a  principal 
cause  of  hysteria,  every  organ  should  be  examined, 
and,  if  really  diseased,  the  disorder  should  be  corrected 
if  possible.  The  physician  will,  of  course,  bear  in 
mind  the  fact  that  functional  disturbances  may  be 
found  in  any  part  of  the  system.  He  will  also  do  well 
to  bear  in  mind  that  too  much  notice  given  by  him  to 
any  organ  may  call  the  patient's  attention  to  that  part 
of  the  body,  and  so  its  condition  be  made  worse.  This 
tendency  of  the  patient  may  be  utilized  by  the  physi- 
cian to  turn  the  patient' s  attention  away  from  the  dis- 


HYSTERIA.  367 

eased  organ  while  he  really  administers  medicine  for 
that. 

The  management  of  the  patient  between  the  attacks 
is  of  great  importance ;  or,  if  there  has  been  no  fully- 
developed  attack,  but  only  such  an  unstable  nervous 
condition  as  to  give  rise  to  fear  of  an  attack,  the  gen- 
eral management  is  important.  This  will  include  hy- 
gienic and  dietetic  agencies ;  but  care  must  also  be 
given  to  develop  the  patient's  power  of  will,  of  self- 
restraint,  and  her  ability  to  meet  and  resist  the  ordi- 
nary little  disturbances  which  arise  in  daily  life,  as 
well  as  the  more  serious  trials.  The  physician  would 
not  be  wise  to  entirely  ignore  the  patient's  complaints  ; 
he  should  not  set  aside  the  symptoms  mentioned  as  eu: 
tirely  imaginary,  but,  while  letting  the  patient  feel  that 
she  has  his  sympathy,  and  that  he  understands  her 
troubles,  he  should  also  show  her  that,  by  a  resolute 
effort  of  will,  she  can  do  much  to  help  herself.  He  can 
not  do  this  on  the  first  visit,  nor  perhaps  until  after  he 
has  allowed  time  enough  to  elapse  to  win  her  confi- 
dence. In  other  cases,  comparative  harshness  and  dis- 
regard of  complaints  from  the  first  will  have  a  better 
effect.  It  will  sometimes  be  necessary  to  remove  the  pa- 
tient from  home,  and  to  seclude  her  in  a  measure,  or  en- 
tirely, giving  her  into  the  care  of  kind  but  firm  nurses. 

The  boundary  between  hysteria  and  insanity  is  by 
no  means  well  defined,  and  the  question  may  arise  as  to 
the  propriety  of  asylum  treatment.  Each  case  must  be 
judged  upon  its  own  merits. 

Of  drugs  which  may  be  used,  those  which  will  act 
as  tonic  to  the  nervous  system,  and  increase  the  vigor 
of  the  health  generally,  should  be  given,  in  order  to 
remedy  the  natural  predisposition  of  the  patients.  Be- 
sides the  ordinary  tonics,  arsenic,  zinc,  and  phosphorus, 
in  their  different  pharmaceutical  forms,  may  prove  of 
benefit ;  valerianate  of  zinc,  in  two-  or  three-grain  doses, 
is  specially  valuable.  Cod-liver  oil,  or,  if  that  can  not 
be  taken,  cream,  is  a  useful  addition  to  the  diet.    If  the 


368  UNCLASSIFIED. 

heart  is  irregular  or  feeble,  a  short  course  of  digitalis 
may  be  of  value. 

Hysterical  patients  are  very  often  addicted  to  tlie 
use  of  preparations  of  opium  to  relieve  real  or  imagi- 
nary pain.  Opiates  should  be  used  with  extreme  cau- 
tion. A  patient  who  has  taken  much  opium  loses  her 
power  of  bearing  pain,  and  when  to  the  slight  discom- 
fort is  added  the  craving  for  the  drug,  she  can  not  or 
will  not  distinguish  between  the  two  sensations,  and 
calls  loudly  for  the  opiate.  If  it  is  withheld,  the  need 
of  it  ceases  after  a  while.  Of  course,  if  the  patient  is 
a  confirmed  opium-taker,  the  task  of  weaning  her  from 
the  habit  becomes  the  more  difficult. 

As  a  substitute  for  opium,  recourse  may  be  had  to 
external  applications,  to  atropia,  hyoscyamus,  conium, 
and  cannabis  Indica ;  subcutaneous  injections  of  water 
will  sometimes  be  of  advantage. 

Bromide  of  potassium  and  chloral  had  better  be 
used  only  occasionally.  If  their  use  is  habitual,  the 
result  is  bad.  Sleeplessness  can  be  remedied  often  by 
massage,  by  exercise,  by  healthy  occupation  of  the 
mind,  by  removing  digestive  disturbances,  sometimes 
by  a  meal  or  a  slight  stimulant  given  at  bed-time.  Care 
should  be  exercised  in  using  alcoholic  stimulants,  as 
hysterical  patients  easily  acquire  a  craving  for  such. 

During  an  emotional  attack,  various  preparations  of 
valerian,  asafoetida,  musk,  etc.,  can  be  given  ;  yet  they 
are  by  no  means  always  successful.  Inhalations  of 
nitrite  of  amyl,  ammonia,  and  ether  can  be  tried. 

The  convulsive  attacks  can  sometimes  be  cut  short 
by  a  command  given  in  a  sudden  and  authoritative  man- 
ner ;  at  other  times  a  slap,  or  a  glass  of  water  thrown 
in  the  face,  may  stop  the  attack.  There  are  some  ob- 
jections to  this  procedure,  especially  as  the  water  wets 
both  patient  and  bed.  In  hystero-epilepsy,  compression 
of  the  ovary  will  almost  always  cut  short  the  attack  ; 
the  compression  must  be  directed  toward  the  ovary, 
and  be  quite  strong. 


HYSTERIA.  369 

An  ice-bag  placed  over  the  hypersestlietic  ovary  for 
half  an  hour,  or  longer,  morning  and  evening,  may 
have  a  beneficial  effect  in  diminishing  the  frequency  of 
convulsive  attacks.  Blisters  may  produce  a  similar 
effect. 

Fere  has  caused  an  ovarian  compressor  to  be  made 
which  can  be  worn  by  the  patient ;  this  causes  the  at- 
tacks to  be  postponed.  Inhalation  of  ether  may  cause 
the  attack  to  cease. 

An  indifference  to  attacks,  in  which  the  patient  does 
not  lose  consciousness,  is  a  useful  means  of  diminish- 
ing their  frequency  and  their  violence,  while  too  much 
curiosity  and  attention  will  cause  the  attacks  to  be 
more  frequent  and  more  severe. 

The  question  of  removal  of  the  ovaries  has  been 
somewhat  discussed.  Several  cases  of  recovery  have 
been  reported.  The  operation  should  be  kept  in  mind 
with  reference  to  severe  intractable  cases  where  there 
is  evident  disease  of  the  organs. 

The  phenomena  called  metallotherapy  are  of  con- 
siderable interest.  In  some  cases  of  hystero-epilepsy, 
if  a  metal  disk  is  bound  upon  an  anaesthetic  part,  in 
ten  to  twenty  minutes  sensation  returns  ;  the  return  of 
sensation  is  preceded  or  accompanied  by  a  pricking 
sensation.  The  return  of  sensation  is  not  confined  to 
the  area  covered  by  the  metal,  but  extends  beyond  the 
disk,  mostly  parallel  with  the  axis  of  the  limb,  if  the 
metal  is  on  a  limb.  Patients  are  not  all  susceptible  to 
the  same  metal ;  one  may  be  influenced  by  iron,  an- 
other by  copper,  another  by  lead,  and  so  on. 

When  sensation  returns  in  a  part  of  the  anaesthetic 
side  in  consequence  of  the  application  of  metal,  it  will 
be  found  that  a  corresponding  spot  of  skin  on  the 
sound  side  has  lost  its  hypersesthesia. 

There  may  be  a  similar  transfer  of  muscular  power, 
of  vision,  of  hearing,  taste,  and  smell.  The  circula- 
tion is  affected,  and  the  temperature  may  be  altered. 

When  the  metal  disk  is  removed,  the  anaesthesia, 

24 


370  UWGLASSIFIED. 

etc.,  oscillates  for  a  short  time  between  the  two  sides, 
until  finally  the  parts  recover  their  previous  condition. 
Only  a  small  proportion  of  the  patients  affected  receive 
any  permanent  benefit  from  these  applications. 

Burq  first,  in  recent  times,  called  attention  to  this 
influence  of  metals.  Charcot,  his  pupils,  and  many 
others,  have  followed  up  these  investigations.  Many 
curious  and  interesting  facts  have  been  learned  which 
can  not  be  given  here. 

Among  agents  which  have  been  experimented  with, 
and  which  may  be  used  with  some  benefit,  especially 
in  hystero-epilepsy,  may  be  mentioned  the  magnet,  the 
application  of  which,  to  the  skin,  causes  a  transfer  of 
sensation.  Static  electricity,  in  the  form  of  direct  dis- 
charges, or  discharges  from  Leyden  jars,  will  cause  a 
transfer ;  prolonged  static  baths  are  said  to  have  a  per- 
manent effect. 

The  application  of  both  the  galvanic  and  inter- 
rupted currents  are  often  of  value.  The  application 
may  be  made  to  the  affected  parts :  if  there  is  anaes- 
thesia, the  wire  brush  to  the  skin ;  if  paralysis,  the 
skin  should  be  moistened,  so  that  the  electricity  can 
pass  through  to  the  muscles.  Beard  and  Rockwell's 
method  of  general  electrization  may  be  used;  the 
feet  of  the  patient  are  put  in  a  basin  of  water  (not  a 
metallic  basin),  in  which  one  pole  is  placed ;  the  other 
pole  may  be  passed  over  the  patient's  neck  and  shoul- 
ders, or  may  be  placed  in  another  basin  of  water,  in 
which  his  hands  are  dipped. 


CHAPTER  XXXII. 

NEUEASTHENIA. 

Mitchell,  S.  Weir,  Fat  and  Blood.  Philadelphia,  1884.— 
Beard,  G.  M.  ,  A  Practical  Treatise  on  Nervous  Exhaustion.  New 
York,  1880. — MITCHELL,  Lectures  on  the  Diseases  of  the  Nervous 
System.  Philadelphia,  1881. — Playpair,  W.  S.,  The  Systematic 
Treatment  of  Nerve-Prostration  and  Hysteria.  London,  1883. — 
Clark,  F.  le  Gros,  Some  Remarks  on  Nervous  Exhaustion  and 
on  Vaso-Motor  Action.  Jour,  of  Anat.  and  Physiol. ,  April,  1884, 
p.  339. 

Neurasthenia  means  simply  an  exhaustion,  and  con- 
sequent weakness,  of  the  nervous  system  in  general. 
During  the  last  few  years  this  condition  has  attracted 
much  attention,  and  has  been  looked  upon  as  a  sepa- 
rate, independent  affection.  Beard  led  the  attention 
in  recent  years  to  the  many  various  disturbances  which 
can  be  classed  under  this  head. 

Etiology. — The  causes  of  neurasthenia  are  very 
numerous,  the  most  important,  perhaps,  being  the  mode 
of  life,  habits,  and  customs  of  the  present  generation. 

Heredity  certainly  plays  an  important  part  in  the 
aetiology,  many  of  the  patients  having  a  father  or  moth- 
er, or  both  parents,  similarly  affected,  or  suffering  from 
some  debilitating  disease,  as  phthisis.  Women  are  the 
most  subject  to  the  disease,  although  men  are  by  no 
means  exempt. 

Of  other  causes,  the  training  which  the  child  re- 
ceived in  its  infancy  and  early  years  acts  powerfully ; 
the  school-life  and  the  home-life  both  aid  in  develop- 
ing a  weakened  nervous  constitution.  In  adult  years, 
the  wear  and  tear  of  business  and  of  social  life,  the 


372  UNCLASSIFIED. 

anxieties  and  worries,  tlie  disappointments  frequently 
met  in  the  struggle  for  existence,  aid  also  in  tlie  same 
direction.  The  way  houses  are  built,  the  way  they  are 
warmed  and  ventilated,  habits  in  regard  to  diet,  in  re- 
gard to  sleeping,  exercise,  employment,  and  amuse- 
ment, must  be  reckoned  as  favoring  the  development 
of  this  affection.  To  go  into  particulars  would  require 
an  enumeration  of  every  violation  of  the  laws  of  health 
and  hygiene  which  are  so  common  at  the  present  time. 

Pathological  Anatomy. — There  is  probably  no 
special  pathological  change  to  be  discovered  on  inspec- 
tion, or  the  minutest  examination  of  the  nervous  sys- 
tem. In  the  vast  majority  of  cases  the  disturbance  is 
purely  functional,  at  least  in  the  commencement.  In  a 
few  cases  there  is  a  strong  suspicion  or  probability 
that  the  nervous  exhaustion  leads  finally  to  structural 
changes,  as  sclerosis  ;  this  is,  however,  by  no  means 
positively  proved.  Most  patients,  however,  have  an 
unhealthy  complexion.  There  is  an  expression  about 
the  eyes  and  mouth  which  is  characteristic.  The  gait 
and  other  movements  of  the  patient  are  also  more  or 
less  characteristic  of  the  languor  and  discomfort  expe- 
rienced. These  peculiarities  can  not  be  well  described, 
but  can  be  learned  by  observation. 

Symptoms. — A  patient  usually  comes  only  gradu- 
ally to  realize  that  his  health  is  impaired. 

The  first  symptoms  are  those  of  languor,  of  disin- 
clination for  exertion.  The  patient  finds  it  necessary 
to  rouse  himself  by  an  effort  of  the  will  to  perform  his 
daily  duties.  This  languor  and  lassitude  may  be  ac- 
companied with  more  or  less  discomfort  in  the  head, 
perhaps  amounting  to  pain  ;  or  there  may  be  a  sense  of 
weakness  across  the  back,  and  pain  along  the  spine. 
Sometimes  there  are  various  abnormal  sensations  in  the 
limbs. 

Attending  the  pain  in  the  head  or  back,  there  is 
usually  more  or  less  tenderness  on  pressure  over  the 
scalp,  or  the  spinous  processes  of  the  vertebrae.     The 


NEURASTHENIA.  373 

back  of  tlie  head  and  upper  part  of  the  neck  are  very- 
likely  to  be  the  seat  of  the  pain.  This  tenderness  may 
be  excessive.  This  is  the  condition  which  has  been 
called  "spinal  irritation."  It  is  often  attended  with 
motor  and  sensory  disturbance  of  the  limbs,  according 
to  the  level  at  which  it  may  be.  There  is  no  need  to 
raise  this  symptom  to  the  dignity  of  a  separate  affec- 
tion ;  it  is  merely  the  result  of  the  general  nervous  ex- 
haustion localized. 

]S"oises  in  the  ears,  of  various  kinds,  may  also  be 
noticed.  The  pupils  may  be  widely  dilated,  or  have  an 
unusual  mobility. 

Loss  of  sleep  is  sometimes  very  distressing ;  the  pa- 
tient may  find  it  diflBcult  to  get  asleep,  and  lie  awake 
half  the  night,  or  he  may  have  no  difficulty  in  dropping 
to  sleep  when  he  first  goes  to  bed,  but,  waking  up  after 
an  hour  or  two,  lies  awake  for  several  hours.  Some- 
times, when  the  sleep  seems  to  be  sound  during  the 
whole  night,  the  patient  awakes  unrefreshed,  feeling  as 
tired  as  when  he  went  to  bed.  It  is  no  uncommon 
thing  to  have  the  patient  feel  sleepy  before  going  to 
bed,  unable  to  do  anything  on  account  of  the  extreme 
drowsiness,  and  then,  on  retiring,  he  is  as  wide  awake 
as  possible. 

When  the  disturbance  has  continued  some  time, 
and  advanced  considerably,  there  may  be  an  irritability 
of  temper  and  a  change  of  disposition,  which  renders 
it  very  trying  to  get  along  with  such  patients.  He  may 
be  unable  to  control  his  mental  operations.  Reading 
even  a  few  seutences  is  fatiguing,  or  it  is  impossible  to 
understand  anything  that  is  read,  so  that  all  intellect- 
ual work  must  perforce  be  abandoned. 

Various  disturbances  of  the  secretions,  either  a  de- 
ficiency or  an  increase  of  perspiration,  or  of  the  saliva, 
or  of  urine,  show  that  the  secretory  functions  are  inter- 
fered with.  Many  patients  cry  very  easily  in  a  hys- 
terical manner. 

The  voice  may  be  changed  and  peculiar.     A  com- 


374:  UNCLASSIFIED. 

plaining,  weak,  high-pitched  voice  is  sometimes  met. 
The  vaso-motor  system  shows  a  certain  amount  of  in- 
stability. It  is  common  for  patients  to  blush  easily  on 
the  slightest  provocation.  There  is  also  frequently  a 
sensation  of  heat,  flushing  of  the  face  and  head,  which 
at  times  is  extremely  disagreeable,  almost  painful.  This 
sense  of  heat  may  also  be  experienced  through  the  back 
and  limbs,  and  alternate  with  chills  creeping  over  the 
body. 

Perhaps,  owing  in  part  to  the  instability  of  the  vaso- 
motor system,  these  patients  are  very  susceptible  to 
changes  of  weather ;  especially,  dull,  cloudy,  and  cold 
weather  is  found  to  be  disagreeable.  Many  times,  also, 
the  heat  of  summer  is  oppressive,  though  the  patients 
very  often  desire  the  rooms  in  which  they  dwell  during 
the  winter  to  be  kept  at  a  high  temperature.  The 
strength  is  very  easily  exhausted.  Having  no  reserve 
force,  if  there  is  an  extra  demand  for  exertion  they 
find  themselves  unable  to  meet  the  emergency,  and 
hence  are  quickly  tired.  They  may  be  entirely  inca- 
pacitated for  the  ordinary  duties  of  life,  in  consequence 
of  lack  of  power  for  sustained  exertion. 

The  symptoms  in  neurasthenia  change  and  vary 
from  time  to  time  even  in  the  same  patient.  There  are 
no  two  patients  in  whom  the  group  of  symptoms  is 
the  same.  Also,  the  symptoms  can  not  be  reconciled 
with  an  organic  change  in  any  part  of  the  nervous  sys- 
tem. They  are  too  variable  and  too  contradictory  to 
have  any  such  sound  basis.  Many  of  these  patients 
are  more  or  less  hysterical,  and  it  is  sufficient  that  the 
physician  should  mention  symptoms  for  the  patient 
to  have  them  at  the  next  examination. 

DiAGisrosis. — The  diagnosis  of  nervous  exhaustion 
can  be  made  only  after  a  careful  study  of  the  symp- 
toms, both  subjective  and  objective. 

The  accounts  already  given  of  various  organic  dis- 
eases, with  their  symptoms,  will  be  sufficient  to  enable 
any  one,  after  a  careful  examination,  to  decide  whether 


NEURASTEENIA.  375 

there  is  any  siicli  organic  change.  If  not,  and  if  tlie 
symptoms  are  frequently  changing,  and  if  the  patient 
has  a  semi-hysterical  appearance,  seems  to  be  dwelling 
a  great  deal  upon  his  own  symptoms,  over -anxious 
about  himself,  it  will  be  pretty  safe  to  decide  that  there 
is  no  organic  change,  but  that  the  disturbance  is  simply 
nervous  exhaustion. 

Pkognosis. — The  chances  of  recovery  in  these  pa- 
tients depends  a  great  deal  upon  whether  the  exhaus- 
tion is  excessive,  and  whether  the  patients  have, 
through  several  years,  gradually  reached  the  condition 
in  which  they  are  found. 

At  the  very  best,  it  will  require  many  months,  per- 
haps years,  for  a  satisfactory  recovery  ;  and,  if  the  pa- 
tient is  somewhat  advanced  in  years,  he  can  never 
regain  the  vigor  of  earlier  life.  Death  almost  never 
results  as  a  consequence  of  nervous  exhaustion,  though 
it  is  possible  that,  after  several  years,  organic  changes 
may  be  set  up  in  the  nervous  system,  which  may  then 
lead  to  a  fatal  termination. 

Insanity,  especially  melancholia,  is  not  very  likely 
to  occur  as  the  sequel  of  neurasthenia.  Many  patients 
neither  get  well  nor  grow  worse,  but  live  an  invalid 
life,  suffering  greatly,  having  very  little  comfort  in 
themselves,  and  feeling  that  they  are  a  burden  and  care 
to  their  friends,  until  some  intercurrent  disease  ends 
their  life. 

Teeatmeistt. — One  of  the  first  requisites  in  treat- 
ment of  such  patients  is  rest,  and  many  of  the  patients 
require  bodily  as  well  as  mental  rest.  If  the  disease  is 
but  slightly  advanced,  it  may  be  sufficient  to  send  the 
patient  away  from  home  to  get  him  out  of  the  regular 
ruts  of  life,  away  from  business  and  its  cares,  or,  in  the 
case  of  women,  away  from  household  duties  and  anxie- 
ties, or  the  excitement  of  fashionable  life. 

Traveling  is  rarely  of  benefit.  It  is  better  for  the 
patient  to  go  to  some  retired  place  where  recreation  and 
amusement  can  be  obtained  sufficient  to  make  the  time 


376  UNCLASSIFIED. 

pass  pleasantly,  and,  settling  down,  lie  should  deter- 
mine to  obtain  the  greatest  amount  of  rest  possible. 

In  cases  where  the  disease  is  rather  advanced,  it  is 
much  better  that  the  patient  should  be  taken  away  from 
home,  away  from  the  care  and  the  sympathy  of  friends, 
placed  among  comparative  strangers,  and  subjected  to 
the  treatment  which  Weir  Mitchell  has  so  ably  de- 
scribed in  his  two  little  books.  This  treatment  con- 
sists in  putting  the  patient  to  bed,  feeding  systematic- 
ally at  first  with  milk,  and  later  with  other  easily 
assimilated  food,  supplying  the  place  of  exercise  by 
massage  and  electricity. 

These  patients  usually  have  much  trouble  in  sleep- 
ing. It  may  at  first  be  necessary  to  give  various  reme- 
dies in  order  to  obtain  quiet  rest  at  night.  A  good  dose 
of  opium,  or  occasionally  bromide  of  potassium,  may 
be  of  advantage.  The  bromide,  however,  should  be 
given  in  divided  doses,  beginning  about  the  middle  of 
the  day,  so  that  the  patient  will  take  three  doses  before 
night.  Chloral  should  rarely  be  given ;  paraldehyde 
in  doses  of  thirty  to  fifty  minims  is  much  better.  Vale- 
rianate of  zinc,  combined  with  extract  of  hyoscyamus 
and  extract  of  conium,  as  in  the  following  prescription  : 

1^  Zinci  valerianatis gi"-  ij ; 

Exthyoscyami,)      .^  _    ^ 

Ext.  conii,  )  ° 

Ft.  pil. 

given  three  times  a  day,  will  sometimes  quiet  the  nerv- 
ous restlessness,  and  favor  sleep  better  than  anything 
else.  This  combination  also  has  the  advantage  of  be- 
ing slightly  laxative.  If  there  is  instability  of  the  vaso- 
motor system,  flushings,  and  chills,  it  may  be  an  ad- 
vantage to  combine  with  this  ergot,  cod-liver  oil,  and 
other  tonics ;  arsenic,  iron,  strychnia,  etc.,  may  be 
given  as  seems  most  desirable. 

Electricity  is  useful,  not  only  to  obtain  the  passive 
exercise  of  the  muscles,  but,  given  in  the  form  of  gen- 


NEURASTEENIA.  377 

eral  faradization,  as  described  by  Beard  and  Rockwell, 
is  often  of  very  great  advantage,  acting  as  a  general 
tonic  ;  the  static  form  is  also  useful. 

It  may  be  well  to  say  a  few  words  in  regard  to  feed- 
ing. Most  of  these  patients  are  underfed.  In  many 
tliere  is  nervous  dyspepsia,  and  the  stomach  will  bear 
but  a  small  amount  of  food  at  one  time.  It  is  neces- 
sary, therefore,  to  feed  frequently.  Occasionally  as 
often  as  every  half -hour  a  few  spoonfuls  may  be  given. 
Milk,  or  some  of  the  various  preparations,  as  Ridge' s 
Food,  or  Mellin's  Food,  can  be  given  at  first,  but  soon 
other  things  may  be  joined  with  it,  as  has  been  already 
mentioned  in  regard  to  the  feeding  of  patients. 

To  carry  out  a  successful  treatment  of  these  patients 
requires  a  great  deal  of  tact  and  perseverance  on  the 
part  of  both  the  physician  and  the  patient.  The  pa- 
tient must  stay  in  bed  long  enough.  The  mistake  is 
more  frequently  made  of  not  keeping  the  patients  con- 
fined as  long  as  is  necessary  rather  than  of  keeping 
them  in  bed  too  long. 

The  methods  of  treatment  while  the  patient  is  in 
bed  must  be  changed  and  varied  as  circumstances  re- 
quire. Where  there  is  extreme  exhaustion,  very  little 
attention  needs  to  be  paid  to  the  amusement  or  the 
recreation  of  the  patient  while  thus  confined.  As  the 
patient,  however,  gains  strength,  it  may  be  well  to  al- 
low some  reading.  After  a  while  the  patient  may  be 
allowed  to  read  a  little  himself.  Then  other  light  em- 
ployments may  be  gradually  taken  up ;  but  it  is  neces- 
sary to  remember  that  sewing,  knitting,  crocheting,  etc., 
are  really  a  severe  tax  upon  the  muscular  system,  and 
will  often  of  themselves  produce  pain  in  the  back  and 
head,  so  that  it  is  necessary  to  limit  the  time  of  such 
employment. 

When  the  patient  begins  to  get  up,  it  will  be  neces- 
sary to  carefully  regulate  the  amount  of  exercise  and 
exertion,  in  order  that  he  may  not  overtax  himself,  and 
so  be  put  back  and  delayed  in  recovery. 


378  UNCLASSIFIED. 

Many  times  it  is  necessary  to  confine  the  patient  to 
the  bed  all  day  long.  He  can  change  from  bed  to 
lounge,  or  couch,  and  back  again.  At  first  it  may  be 
necessary  to  exclude  friends  ;  but,  later,  a  friend,  who 
has  the  wisdom  not  to  stay  too  long  and  not  talk  too 
fast  or  much,  and  who  does  not  tire  the  patient,  may 
be  admitted  as  may  seem  most  desirable. 


CHAPTER  XXXIII. 

TETANUS  AND  TETANY. 

AUFRECHT,  Zur  pathol.  Anatomie  des  Ruckenmarks  beim  Te- 
tanus. Deut.  med.  Wochen.,  No.  14,  15,  1878,  and  London  Med. 
Eec,  June  15,  1878,  p.  238.— Coats,  J.,  On  the  Pathology  of  Tet- 
anus and  Hydrophobia.  Med.-Chir.  Trans.,  61,  1878,  p.  79. — 
Woods,  G.  A.,  A  Contribution  to  the  Pathology  of  Tetanus.  Lan- 
cet, Sept.  7,  1878,  p.  326.— Wood,  H.  C,  Abstract  of  a  Lecture  on 
a  Case  of  Idiopathic  Tetanus.  Philadelphia  Med.  Times,  March 
15,  1879,  p.  273.  —  Knecht,  Beitrage  zur  Lehre  vom  Tetanus, 
Schmidts  Jahrh.,  181,  182,  1879.— Macdougall,  J.  A.,  The  eti- 
ology of  Tetanus,  etc.  Lancet,  July  19, 1884,  p.  98. — Bowlby,  A. 
A.,  Five  Cases  of  Tetanus,  with  some  Remarks  on  its  Pathology. 
St.  Barth.  Hosp.  Rep.,  1883,  p.  85. 

Tetany.— Trousseau,  Lectures  on  Clinical  Medicine.  New 
Syden.  Soc,  1868,  vol,  i, — Erb,  W,,  Zur  Lehre  von  Tetania. 
Arch.  f.  Psych.,  iv,  1874,  p.  271. — Chyostek,  Beitrag  zur  Tetanie. 
Wien.  med.  Presse,  1876,  1878,  1879.— Weiss,  N,,  Ueber  Tetanie. 
Volkmann's  Sammlung,  No.  189,  1881. — Gowers,  W,  R.,  Clini- 
cal Lecture  on  Tetany.    Lancet,  July  21,  1883,  p,  93, 

TETANUS  (Locked- Jaw). 

Tetanus  is  a  continuous  tonic  spasm  of  the  muscles, 
due  to  an  increase  of  the  reflex  irritability  in  conse- 
quence of  an  injury,  though  sometimes  apparently  the 
result  simply  of  a  chill. 

Etiology. — Injuries  of  the  extremities  are  more 
frequently  the  cause  of  tetanus  than  those  of  the  trunk. 
Both  severe  and  slight  wounds  may  be  followed  by  the 
spasms,  which  may  occur  before  the  wound  is  healed, 
or  only  a  long  time  afterward. 

Exposure  to  the  inclemency  of  the  weather,  and 
various  hardships,  also  lack  of  cleanliness  in  the  care 


380  UNCLASSIFIED. 

of  the  wound,  are  more  likely  to  be  associated  as  causes 
of  tlie  attack. 

The  disease  is  somewhat  common  in  military  sur- 
gery, and  the  soldiers  of  the  vanquished  party  are  more 
likely  to  be  affected  than  the  victors.  In  civil  life,  men 
are  more  commonly  affected  than  women,  being  more 
exposed  to  injuries. 

The  disease  is  very  common  in  certain  countries  in 
new-born  children,  especially  during  the  first  nine  days 
of  life. 

Children  are  more  likely  to  be  affected  in  warm  cli- 
mates ;  and  there  are  also  districts  in  temperate  zones 
where  the  disease  is  more  likely  to  occur,  as  along  the 
southern  and  eastern  shore  of  Long  Island. 

It  is  said  that  the  colored  races  are  more  likely  to 
be  attacked  than  whites. 

Symptoms. — The  first  symptom  is  usually  a  stiffness 
of  the  jaws  (trismus),  which  renders  it  somewhat  diffi- 
cult to  open  the  mouth.  Then  there  is  a  slight  spasm 
in  the  muscles  of  the  neck,  and  later  this  spasm  ex- 
tends to  the  muscles  of  the  back  and  of  the  trunk. 
The  severity  of  the  contraction  steadily  increases,  and, 
the  extensors  being  the  most  powerful,  the  body  is  gen- 
erally drawn  backward,  so  as  to  form  an  arch,  and, 
when  the  spasm  is  extreme,  the  patient  rests  upon  his 
head  and  heels,  the  body  being  arched  above  the  bed 
(opisthotonus). 

The  arms  and  hands  are  often  unaffected,  though 
they  may  be  rigid  in  extension. 

The  contraction  of  the  muscles  is  attended  with  se- 
vere, cramp -like  pains,  producing  extreme  distress. 
The  skin  is  frequently  covered  with  perspiration  dur- 
ing the  spasm.  The  contraction  of  the  respiratory 
muscles  interferes  with  breathing,  so  that  at  the  height 
of  the  spasm  the  patient  has  a  sensation  of  impending 
suffocation.  Owing  to  the  closure  of  the  jaws,  the-pa- 
tient  finds  great  difficulty  in  speaking,  and  it  is  almost 
impossible  to  feed  him. 


TETANUS.  381 

The  muscles  are  continuously  in  a  state  of  contrac- 
tion, but  are  not  always  contracted  to  sucli  an  extreme 
degree,  remissions  occurring,  during  whicli  the  patient 
may  resume  the  ordinary  position  in  bed,  be  able  to 
take  food,  and  converse ;  yet  the  slightest  irritation, 
even  breathing  upon  the  patient,  or  a  slight  jar  of  the 
room,  or  an  attempt  to  swallow,  will  cause  a  recurrence 
of  the  extreme  spasm. 

The  temperature  is  but  little  affected  except  Just  be- 
fore death,  when  it  may  rise  as  high  as  112"^  or  113°. 
The  pulse,  also,  is  nearly  normal,  except  toward  death 
it  may,  with  the  rise  of  temperature,  become  very  rapid. 

The  mind  is  usually  unaffected,  except  toward  the 
close  of  life,  when  there  may  be  delirium.  Occasion- 
ally the  patient  dies  in  consequence  of  the  disturbance 
of  resiDiration ;  but  this  is  not  very  common.  Many 
times  the  patient  dies  in  the  interval  between  the 
spasms,  apparently  worn  out  by  the  disease. 

Pathological  Aisr atomy. — The  pathological  changes 
found  in  tetanus  do  not  explain  the  symptoms,  nearly 
all  being  apparently  the  effects  of  the  disease  rather 
than  the  cause. 

In  many  cases,  however,  inflammation  of  the  nerves 
leading  from  the  seat  of  the  wound  have  been  recog- 
nized, and  occasionally  there  have  been  found  changes 
in  the  spinal  cord,  the  blood-vessels  being  surrounded 
by  leucocytes.  Ross  mentions  finding  these  bodies 
in  the  gray  and  white  substance,  around  the  vessels, 
though  not  usually  aggregated  in  the  perivascular 
spaces,  as  in  hydrophobia.  He  also  found  some  changes 
in  the  ganglion-cells  of  the  anterior  cornua. 

DiAGisrosis. — It  is  scarcely  possible  to  mistake  teta- 
nus when  well  marked. 

It  is  important  to  make  a  diagnosis  as  early  as  pos- 
sible, even  when  there  is  only  the  first  symptom  of  tris- 
mus. 

Strychnia-poisoning  resembles  tetanus  in  some  re- 
spects, but  the  spasms  are  less  continuous,  having  pe- 


382  UNCLASSIFIED. 

riods  of  entire  intermission ;  also  the  reflex  irritability 
is  somewhat  less  marked,  and  the  disease  begins  more 
abruptly,  affecting  the  limbs  first  rather  than  the  mus- 
cles of  mastication  and  the  neck. 

Peognosis. — The  disease  is  always  a  grave  affection  ; 
seventy  per  cent  or  more  die. 

It  is  less  serious  when  the  result  of  cold  than  when 
there  has  been  a  previous  wound  or  injury.  The  longer 
the  time  after  the  injury  when  the  first  symptom  ap- 
pears, the  more  favorable  the  prognosis.  Infants  al- 
most always  die. 

Teeatment. — The  patient  should  be  put  in  a  dark 
room,  kept  as  quiet  as  possible,  and  every  possible  effort 
made  to  prevent  any  impressions  which  would  excite 
the  spasm.  One  of  the  most  diflBcult  problems  is  how 
to  feed  the  patient.  It  is  absolutely  necessary  to  keep 
up  his  strength,  and  the  feeding  should  be  done,  in  the 
most  quiet  way,  with  liquid  nourishment,  so  as  to  re- 
quire as  little  effort  on  the  part  of  the  patient  as  pos- 
sible. 

The  jaws  being  closely  locked,  it  may  be  necessary 
to  pass  the  food  in  by  a  tube  behind  the  teeth.  It  has 
been  recommended  to  feed  the  patient,  while  under  the 
influence  of  ether,  by  means  of  a  tube  passed  through 
the  nostril  into  the  stomach. 

Of  antispasmodic  drugs,  almost  all  in  the  Pharma- 
copoeia have  been  used  at  different  times.  Curare  and 
calabar-bean  have  been  used  to  diminish  the  reflex  irri- 
tability. Chloral  and  bromide  of  potassium  together 
are  of  great  advantage,  but  it  is  necessary  to  give  large 
doses.  As  high  as  sixty  grains  of  chloral  have  been 
given,  repeating  it  as  may  be  necessary.  Generally, 
twenty  or  thirty  grains,  with  the  same  amount  of  bro- 
mide of  potassium,  given  every  two  or  three  hours, 
would  be  sufficient.  Thompson  gave  three  grains  daily 
the  first  three  days,  ten  grains  daily  the  next  ten  days, 
five  grains  daily  .the  next  seven  days,  after  that  gradu- 
ally reducing  the  quantity  so  that  in  twenty-six  days 


TETANY.  383 

one  hundred  and  thirty-three  grains  were  taken,  the 
patient  being  a  child  seven  years  old. 

Kead  gave  twenty  drops  of  gelsemium  every  two 
hours,  and  the  next  day  forty  drops  every  two  hours, 
the  patient  recovering. 

The  patient  may  be  kept  under  the  influence  of 
ether,  so  as  to  prevent  the  spasms,  when  other  means 
fail. 

Various  surgical  expedients  have  been  tried ;  the 
nerves  have  been  divided  above  the  seat  of  the  wound. 
Unless  this  is  done  very  soon  after  an  injury,  it  would 
probably  have  but  little  influence.  Stretching  the 
nerve  leading  to  the  wound  has  proved  of  benefit  in  a 
few  cases. 

TETANY. 

Tetany  has  been  sometimes  spoken  of  as  intermit- 
tent tetanus,  sometimes  as  an  intermittent  cramp.  It 
consists  of  spasms  affecting  more  generally  the  upper 
extremity,  in  severe  cases  extending  also  to  the  legs 
and  body,  intermittent,  recurring  at  irregular  inter- 
vals. 

Symptoms. — Trousseau  speaks  of  three  varieties, 
the  mildest,  which  is  local  in  its  manifestations,  being 
confined  to  the  extremities,  usually  the  upper,  some- 
times affecting  the  lower.  The  spasm  consists  chiefly 
in  a  partial  flexion  of  the  fingers,  the  thumb  and  fin- 
gers being  approximated  so  as  to  form  a  cone.  The 
wrist  is  flexed  and  pronated  and  the  forearm  flexed 
upon  the  wrist.  In  the  lower  extremities,  the  toes  are 
flexed,  the  foot  and  leg  extended. 

The  spasm  is  attended  with  severe  pain,  and  any 
effort  to  overcome  it  is  painful. 

The  convulsions  may  last  for  from  five  to 'fifteen  or 
twenty  minutes  ;  the  less  severe  convulsions  may  con- 
tinue two  or  three  hours. 

These  attacks  may  be  repeated  once  a  day,  or  sev- 
eral times  a  day,  for  several  months,  and  then  the  pa- 


381  UNCLASSIFIED. 

tient  may  be  entirely  free,  until  after  some  months  the 
attacks  reappear.  One  of  my  patients  had  these  at- 
tacks regularly  twice  a  year,  lasting  each  time  three 
months. 

Trousseau  has  mentioned  that  in  the  interval  be- 
tween the  spasms  a  compression  over  the  track  of  the 
nerves  or  the  vessels  will  cause  the  attack,  which  con- 
tinues as  long  as  the  compression  is  maintained,  ceas- 
ing as  soon  as  the  pressure  is  removed. 

After  the  attack  there  is  for  a  short  time  loss  of 
power  in  the  limbs  affected.  Sensation  is  likely  also 
to  be  diminished. 

yrousseau'  s  middle  form  of  the  disease  combines 
with  the  spasms  already  mentioned  other  general 
symptoms,  which  he  mentions  as  feverishness,  head- 
ache, loss  of  appetite,  slight  congestions  in  different 
parts  of  the  body ;  the  spasms  are  more  severe,  return 
more  frequently,  and  affect  the  muscles  of  the  trunk 
and  face,  as  well  as  those  of  the  extremity.  He  has  also 
enumerated  a  third  and  more  grave  form  of  the  disease, 
which  differs  in  nothing  from  the  other  except  in  being 
more  severe. 

Sometimes  the  patients  recognize  that  an  attack  is 
approaching,  by  unpleasant  sensations  in  the  hands  and 
feet,  and  slight  stiffness  in  moving. 

Several  authors  have  recognized  a  very  great  in- 
crease of  electrical  irritability  in  both  the  nerves  and 
muscles  of  the  affected  limbs  during  the  attack. 

The  disease  is  of  long  duration  when  once  it  appears, 
extending,  with  the  intermissions,  through  many  years. 

Etiology. — ^Yery  little  is  known  as  to  the  cause  of 
this  disease.  "  Catching  cold  "  is  often  mentioned  as 
the  starting-point  of  the  spasms.  Various  exhausting 
influences  seem  to  act  as  causes.  One  patient  stated 
that  eating  and  drinking  would  bring  on  an  attack  dur- 
ing the  time  when  he  was  liable  to  have  them. 

Pathological  Anatomy. — Very  few  autopsies  have 
been  made,  and  but  little  is  known  as  to  the  changes  in 


TETANY.  385 

the  nerves  or  their  centers,  Weiss  found  swelling  of 
the  ganglion-cells  of  the  anterior  cornua,  with  a  lateral 
position  of  their  nuclei  and  vacuoles  in  the  cells  and 
their  processes  ;  also  atrophy  of  the  cells,  with  loss  of 
their  protoplasmic  processes. 

Diagnosis. — The  character  of  the  spasm,  the  inter- 
mission of  the  attacks,  and  especially  Trousseau's  ma- 
noeuvre of  pressing  upon  the  nerve  or  vessel  of  the  limb, 
are  sufficient  to  determine  the  nature  of  the  disease. 

PEOGisrosis. — The  disease  is  rarely  fatal,  though  a 
few  cases  of  death  have  been  reported.  The  patient, 
having  passed  through  one  attack,  is  not  safe  from  sub- 
sequent attacks. 

Teeatment. — It  seems  as  though  very  little  could 
be  done  to  cut  short  the  spasms.  Opium,  belladonna, 
chloral,  and  inhalations  of  ether  may  be  used  as  indi- 
cated. 

Electricity  may  be  tried,  either  by  faradizing  the 
muscles  that  are  not  affected,  or  the  use  of  galvanism 
to  the  nerve-centers, 

Erb  saw  a  recovery  take  place  from  the  stabile  ap- 
plication of  the  anode  to  the  vertebral  column  and 
the  nerve-trunks  chiefly  affected.  I  used  electricity  in 
one  case  in  every  way  I  could  think  of,  without  a  par- 
ticle of  benefit.  I  have  obtained  more  benefit  from  the 
use  of  the  fluid  extract  of  conium,  twenty  drops  every 
two  hours,  than  from  any  other  remedy.  Between  the 
attacks,  quinine,  arsenic,  and  valerianate  of  zinc,  and 
other  nerve-tonics,  should  be  given. 

25 


CHAPTER  XXXIV. 

MYXCEDEMA. 

Ord,  On  Myxoedema.  Med.-Chir.  Trans.,  Ixi,  1878. — Cushier, 
Elizabeth,  M.,  A  Case  of  Myxoedema.  Archives  of  Med.,  Dec, 
1882,  p.  203. — Oliver,  T.,  Clinical  Lecture  on  Myxoedema.  Brit. 
Med.  Jour.,  March  17, 1883,  p.  502.— Edes,  E.  T.,  Clinical  Lecture 
on  a  Case  of  Myxoedema.  Boston  Med.  and  Surg.  Jour.,  April 
24,  1884,  p.  385.— West,  E.  G.,  A  Case  of  Myxoedema,  with  Au- 
topsy.   Boston  Med.  and  Surg.  Jour.,  July  17,  1884,  p.  50. 

Myxoedema,  consists  essentially  in  an  increase  of  the 
subcutaneous  tissue,  whicli  is  infiltrated  with  mucin, 
so  that  the  general  appearance  is  that  of  oedema,  yet 
the  skin  does  not  pit  on  pressure. 

Symptoms. — The  patient's  appearance  is  very  pecul- 
iar. The  eyelids  are  thick,  as  if  swollen  with  crying, 
or  infiltrated  with  serum ;  the  nose  is  very  broad,  the 
lips  thick,  the  hands  are  large  and  misshapen,  the  fin- 
gers being  club-shaped.  The  feet  are  usually  affected 
the  same  as  the  hands  ;  the  swelling  sometimes  extends 
to  other  parts  of  the  body,  especially  to  the  arms  and 
legs,  and  even  to  the  trunk  itself.  The  tongue  is  usu- 
ally very  much  swollen.  The  patient  has  many  times 
a  waxy  or  anaemic  complexion,  the  red-blood  corpuscles 
being  diminished  in  number.  The  infiltrated  tissue  has 
a  semi-translucent  aiDpearance. 

The  motions  are  necessarily  slow  and  difficult.  The 
patient  manages  his  large  fingers  in  a  clumsy  way,  so 
that  the  more  delicate  manipulations  of  writing  or  sew- 
ing are  illy  performed.  The  gait  of  the  patient  in  walk- 
ing is  slow,  as  if  great  exertion  were  required. 

Ordinary  sensation  is  diminished,  and  the  special 


MYX(EDEMA.  38Y 

sensations  of  taste  and  smell  may  also  be  diminislied, 
probably  on  account  of  the  swelling  of  the  mucous 
membrane  of  the  nose. 

In  some  cases  the  temperature  has  been  noticed  to 
be  above  normal,  but  it  is  usually  diminished.  The 
pulse  is  generally  slow. 

In  most  of  the  cases  observed  the  intelligence  has 
seemed  to  be  affected.  The  patient  answers  questions 
slowly,  as  if  it  were  an  effort  to  think  or  speak.  She 
seems  indifferent  to  her  surroundings.  Memory  may 
be  weakened.  The  simplest  operations  of  arithmetic 
are  performed  with  difficulty,  or  the  patient  is  unable 
to  give  correct  answers. 

Sometimes  the  hair  falls  out.  The  nails  become 
brittle  and  furrowed. 

The  digestion  is  affected  only  when  the  disease  has 
reached  an  extreme  degree. 

Constipation  is  very  common.  Menstruation  is  often 
irregular.  In  some  cases  the  thyroid  gland  has  been 
very  much  diminished  in  size. 

The  succession  of  these  symptoms  may  vary  some- 
what in  different  cases.  Sometimes  the  mental  depres- 
sion, even  reaching  the  degree  of  melancholia,  may  ap- 
pear early  ;  or,  on  the  other  hand,  there  may  be  a  very 
great  amount  of  swelling,  with  the  mind  almost  entirely 
unaffected. 

^TiOLoaY. — The  causes  of  this  disease  are  very  ob- 
scure. In  several  cases  worry  or  anxiety,  or  some  men- 
tal shock,  has  preceded  the  attack.  We,  however,  in 
fact,  know  almost  nothing  in  regard  to  the  real  cause 
of  the  affection. 

The  course  of  the  disease  is  very  slow,  most  of  the 
cases  extending  over  several  years. 

Pathogeistesis. — The  nature  of  this  disease  is  as 
yet  imperfectly  known.  On  the  one  hand,  it  is  sup- 
posed that  the  changes  in  the  skin  are  primary,  and 
that,  owing  to  defective  sensation,  the  cerebral  disturb- 
ance follows  as  a  result  of  the  cutaneous  change. 


388  UNCLASSIFIED. 

Another  view  is  that  the  disease  is  due  to  disturb- 
ance of  the  nervous  system,  either  the  sympathetic  or 
a  more  general  disturbance  involving  other  than  the 
sympathetic  system,  and  the  cutaneous  changes  are 
looked  upon  as  secondary. 

In  the  few  autopsies  which  have  been  made,  the  ex- 
amination has  not  been,  as  a  rule,  complete ;  in  each 
case  some  important  parts  were  overlooked,  and  not  ex- 
amined. Changes  have  been  found  in  the  spinal  cord, 
in  the  blood-vessels,  and  nerve-cells. 

Dr.  E.  M.  Cushier  ("Archives  of  Medicine,"  1882, 
p.  216)  says:  "The  disease  in  question  can  only  be 
described  as  a  nutritive  disturbance,  resulting  in  the 
presence,  in  the  connective  tissue,  of  a  substance  com- 
mon in  embryonic  tissue,  but  not  existing  normally,  ex- 
cepting in  very  small  amounts,  in  adult  life." 

Teeatment  is  comparatively  unsatisfactory  ;  almost 
every  means  of  arresting  the  progress  of  the  disease 
has  failed.  A  few  cases  have  been  reported  in  which 
the  use  of  tonics,  such  as  iron,  quinine  and  strychnia, 
warm-air  baths,  massage,  and  general  hygienic  treat- 
ment, have  seemed  to  be  of  some  advantage.  The  dou- 
ble chloride  of  gold  and  sodium  has  been  recommended. 
Dr.  Edes  refers  to  a  curious  case,  in  which  abdominal 
dropsy  occurred,  and  became  so  severe  as  to  require 
tapping,  after  which  operation  both  the  ascites  and 
myxoedema  disappeared. 


CHAPTER  XXXy. 

TOXIC   NEIJEOSES. 

Lead. — Bernhardt.  Arch.  f.  Psych,  u.  NervenJc.,  iv,  1874,  p. 
601.— Westphal,  C.  Ibid.,  p.  776.— EieGel,  F.  Deut.  Arch.  f. 
kl.  Med.,  1878,  p.  175.— De  Watteville,  A,  Lancet,  July  10, 1880, 
p.  44.— MoNAKOW.  Arch.  f.  Psych.,  x,  1880,  p.  495.— Zunker. 
Zeitschr.f.  M.  Med.,  1880,  p.  496. — Birdsall,  W.  R.  Amer.  Jour, 
of  Neurol,  and  Psych.,  May,  1882,  p.  176. — Webber,  S.  Gr.  Arch, 
of  Med.,  Aug.,  1882.— Putnam,  J.  J.  Boston  Med.  and  Surg. 
Jour.,  1883,  p.  315. 

Arsenic— Seeligmuller,  A.  Deut.  med.  Wochenschr.,  No. 
14,  1881. — Popow,  N.  St.  Petersb.  med.  Wochenschr.,  1881,  p. 
311.— Da  Costa,  J.  M.  Philadelphia  Med.  Times,  March  26, 
July  2,  1881.— Mills,  C.  K.  Med.  News,  March  3,  1883,  p.  257. 
— Seguin,  E.  C.  Jour,  of  Nerv.  and  Mental  Dis.,  Oct.,  1882  ; 
Opera  Minora,  1884. 

Alcohol.— Hutchinson,  J.  E.,  Symptoms  and  Treatment  of 
Alcoholism.  Phila.  Med.  Times,  July  30,  1881,  p.  687.— Pepper, 
William,  On  Acute  Diseases  in  Drunkards — Delirium  Tremens. 
Phila.  Med.  Times,  June  17,  1882,  p.  621.— Atkinson,  F.  P.,  The 
Treatment  of  Delunum  Tremens.  Practitioner,  Jan. ,  1883,  p.  38. 
— Wille,  Ueber  einige  klinische  Beziehungen  des  Alcoholismus 
Chronicus.     Zeitschr.  f.  Psych. ,  1884,  Bd.  xl,  p.  827. 

Hydrophobia. — Benedikt,  M.,  Zur  pathologischen  Anatomie 
der  Lyssa.  Virch.  Arch.,  Bd.  Ixiv,  1875,  p.  557  ;  Bd.  Ixsii,  1878, 
p.  425. — Bollinger.  Ziemssen''s  Cyclop.,  Am.  Trans.,  vol.  iii, 
1875.— Curtis,  T.  B.,  A  Case  of  H.  Boston  Med.  and  Surg.  Jour., 
Nov.  7,  1878,  p.  581  et  seg.— Putnam,  J.  J.,  The  Physiological  Pa- 
thology of  the  Hydrophobic  Paroxysm.  Ibid. ,  Nov.  21,  1878,  p. 
650.— Gowers,  W.  R.  Ibid.,  Feb.  6,  1879,  p.  178.— Foot,  A.  W., 
Report  on  H.  Dublin  Jour.  Med.  Sci.,  Oct.  1,  1879,  p.  287.— Col- 
lins and  Mills,  C.  K.,  Cases,  with.  Microscopic  Report.  Proc. 
Phila.  Co.  Med.  Soc,  1880,  ii,  pp.  107,  117.— Colin,  L.,  Annales 
d'hygien  pub.  May,  1881,  p.  408.— Ruxton,  John,  A  Case  of  Hy- 
drophobia ;  Recovery.    Brit.  Med.  Jour.,  Nov.  19,  1881,  p.  811. — 


390  UNCLASSIFIED. 

Broadbent,  Cases  of  Supposed  Hydrophobia  treated  by  CMoral, 
one  of  which  recovered.  Med.  Times  and  Gaz.,  March  17,  1883, 
p.  308. 

CHRONIC  LEAD-POISONING. 

Lead  may  be  taken  into  the  system  througli  the 
skin,  by  the  mouth  with  food,  or,  inhaled  as  dust,  may 
be  swallowed  with  the  saliva.  The  occupations  in 
which  lead  is  used  are  readily  recognized  in  most  cases  ; 
among  those  less  known  as  dangerous  may  be  men- 
tioned file-cutters,  brush-makers,  workers  in  enamel,  in 
colored  papers,  in  lace,  and  in  rubber-factories. 

Food  preserved  in  tin,  or  drink  passing  through 
lead  pipes,  or  stored  in  lead-lined  cisterns,  not  only  or- 
dinary drinking-water,  but  mineral-waters,  ale,  beer, 
etc.,  are  likely  to  contain  lead. 

Symptoms. — The  time  when  the  symptoms  appear 
after  exposure  varies  from  a  few  days  to  several  years. 

Ancemia  is  one  of  the  earliest  and  most  common 
effects  of  lead.  The  red  corpuscles  may  be  reduced 
one  third  in  number ;  their  size  is  also  slightly  in- 
creased. The  patient  is  sallow ;  the  skin  is  dry  and 
harsh,  sometimes  oedematous.  A  narrow  line  of  bluish- 
purple  color  may  be  frequently  noticed  at  the  edge  of 
the  gums  in  patients  who  do  not  cleanse  their  teeth. 

Lead  colic  is  a  well-known  symptom.  Preceding 
the  attack,  the  appetite  may  have  failed  for  some  days, 
there  may  have  been  a  sweetish  or  disagreeable  me- 
tallic taste,  and  a  general  feeling  of  ill-ease.  Consti- 
pation is  usually  present.  The  pain  is  light  at  first ; 
gradually  increases  until  it  is  of  extreme  severity.  The 
spasms  of  pain  are  usually  of  short  duration,  but  recur 
frequently,  so  as  to  be  almost  continuous.  The  patient 
can  not  keep  quiet ;  he  tosses  about.  Generally  there 
is  no  tenderness  of  the  abdomen ;  pressure  may  give 
temporary  relief  ;  nausea  and  vomiting  may  occur. 

The  pulse  is  hard ;  vascular  tension  is  increased. 
The  sphygmograph  shows  a  slight  notch  at  the  apex  of 


TOXIC  NEUROSES.  391 

the  curve,  a  peculiar  cupping,  by  which  two  points  or 
teeth  are  produced. 

Arthralgia  is  said  to  be  next  in  frequency  to  colic 
as  a  symptom  of  lead-poisoning.  The  pains  resemble 
neuralgia ;  the  joints  are  somewhat  swollen,  and  may 
be  red ;  sometimes  there  are  cramp-like  pains  in  the 
muscles. 

The  paralysis  of  lead-poisoning  usually  affects  the 
extensor  muscles  of  the  fingers  and  wrists ;  is  almost 
always  bilateral,  though  it  may  begin  on  one  side  ear- 
lier than  the  other.  One  or  more  attacks  of  colic,  or 
arthralgia,  may  have  preceded,  and  there  has  generally 
been  abnormal  sensation  in  the  parts,  pricking  and 
tingling,  as  if  the  limb  were  asleep.  The  su^Dinator 
longus  is  rarely  affected  ;  the  deltoid  is  paralyzed  rath- 
er than  the  biceps.  The  flexors  of  the  fingers  always 
seem  weak  when  the  extensors  are  paralyzed.  The  legs 
are  much  less  frequently  affected  than  the  arms  ;  some- 
times the  loss  of  power  is  noticed  in  all  four  limbs. 
When  cosmetics  are  the  cause  of  the  poisoning,  the 
muscles  of  the  face  may  be  paralyzed,  otherwise  they 
are  usually  exempt. 

The  onset  of  the  paralysis  is  gradual ;  sometimes, 
however,  a  day  or  two  is  sufficient  to  render  the  hands 
helpless.  The  muscles  undergo  atrophy,  which  may 
be  extreme.  The  electrical  reaction  is  diminished,  or 
lost ;  the  reaction  of  degeneration  may  be  recognized, 
unless  the  atrophy  has  progressed  too  far. 

There  may  be  partial  loss  of  sensation  on  one  or 
both  sides  ;  this,  however,  is  rare. 

Tremor,  resembling  paralysis  agitans,  is  occasion- 
ally seen. 

Instead  of  symptoms  of  peripheral  paralysis,  those 
of  Tnyelitis  may  be  the  only  evidence  of  lead-poison- 
ing. So  close  is  the  resemblance  that  it  may  be  im- 
possible to  form  a  diagnosis  from  the  symptoms  alone. 
In  order  to  form  a  correct  opinion,  it  will  be  necessary 
to  give  iodide  of  potassium,  and  after  a  week  or  so  ex- 


392  UNCLASSIFIED. 

amine  the  urine  for  lead.  Every  case  of  chronic  mye- 
litis should  be  thus  examined  for  lead. 

The  severest  form  in  which  lead-poisoning  shows 
itself  is  seen  when  the  brain  is  affected— mcej^^aZo- 
pathia  saturnina.  The  symptoms  are  headache,  or 
simply  discomfort  in  the  head,  incapacity  for  mental 
exertion,  amblyopia  and  amaurosis,  delirium,  or  even 
maniacal  excitement,  and  epileptiform  attacks.  Be- 
ginning with  the  milder  manifestations,  the  severe 
symptoms  may  follow  within  a  few  days,  until  a  fatal 
termination  is  reached. 

Many  times  albumen  will  be  found  in  the  urine,  and 
hyaline  casts  are  not  uncommon. 

Pathological  Anatomy. — Lead  has  been  found  in 
nearly  all  the  tissues  of  the  body  ;  but  its  presence  is 
not  constant,  and  the  symptoms  do  not  seem  to  depend 
thereupon. 

The  nerves  supplying  the  paralyzed  muscles  have 
been  found  atrophied  and  degenerated.  Changes  have 
been  found  in  the  nerve-cells  of  the  anterior  cornua  of 
the  spinal  cord,  also  in  the  vessels  of  the  cord.  In 
many  autopsies  no  such  changes  have  been  found. 

The  muscles  undergo  fatty  granular  degeneration. 

Prognosis. — It  is  very  rare  for  lead  colic  and  arth- 
ralgia to  terminate  fatally  ;  relapses,  or  repeated  at- 
tacks, are  usual,  if  the  patient  continues  exposed  to 
lead.  Lead  paralysis  is  also  seldom  fatal  unless  the  ex- 
posure to  the  poison  has  been  very  prolonged,  and  the 
symptoms  have  been  neglected.  Under  proper  treat- 
ment, recovery  is  the  rule  ;  but  many  months  or  years 
may  be  necessary  for  restoration  of  function. 

The  prognosis  in  tremor  from  lead  is  favorable. 

When  the  cerebral  symptoms  are  slight,  chiefly 
headache  and  mental  inertia,  the  chances  of  recovery 
are  good ;  the  same  is  true  even  in  cases  of  delirium 
and  mania,  though  then  the  prospect  is  more  serious. 
In  eclampsia  saturnina  the  patient  almost  invariably 
dies. 


TOXIG  NEUROSES.  393 

Teeatment. — It  is  scarcely  necessary  to  say  tliat 
means  should  be  taken  by  all  workers  in  lead  to  pre- 
vent its  introduction  into  the  system,  or  that,  with  the 
first  symptoms  of  poisoning,  there  should  be  yet  greater 
care. 

Iodide  of  potassium  should  be  given  to  remove  the 
lead  from  the  system.  During  treatment  the  physician 
must  watch  lest  the  liberation  of  lead  from  the  tis- 
sues should  give  rise  to  a  recurrence  of  acute  symp- 
toms. 

Warm  baths  are  of  value,  by  maintaining  the  ac- 
tivity of  the  skin  and  favoring  metamorphosis  of  tis- 
sues. Iodide  of  iron  is  of  value  to  improve  the  quality 
of  the  blood. 

.  During  the  attack  of  colic,  morphia  should  be  freely 
used ;  it  will  aid  in  relaxing  spasm,  and,  with  a  cathar- 
tic, aid  in  opening  the  bowels ;  atropia  may  be  com- 
bined with  it  to  advantage. 

Nitrite  of  amyl  inhaled  may  often  relieve  the  pain 
and  shorten  the  attack  ;  it  also  restores  the  normal  ten- 
sion of  the  vessels  and  the  normal  character  to  the 
sphygmographic  tracing  of  the  pulse. 

To  relieve  the  arthralgia,  warm  baths,  Sometimes 
cold  packing,  and  the  galvanic  current  applied  locally 
to  the  affected  joint,  are  of  value.  Sometimes  tincture 
of  iodine,  though  increasing  the  pain  temporarily,  may 
give  relief  subsequently. 

Paralysis  should  be  treated  by  massage,  warm 
baths,  and  electricity ;  the  interrupted  galvanic  cur- 
rent, if  the  muscles  do  not  react  to  the  faradic.  In  ob- 
stinate cases,  strychnia  by  the  mouth,  or  subcutane- 
ously,  is  said  to  be  of  advantage ;  comparatively  large 
doses  are  required.  The  treatment  must  he  persevered 
in  for  montJis  or  years,  and  not  Tiastily  abandoned. 

In  cases  where  there  seems  to  be  myelitis,  and  in 
cerebral  cases,  the  same  course  should  be  pursued  for 
eliminating  lead.  The  galvanic  current  to  the  head 
will  sometimes  relieve  headache. 


394  UNCLASSIFIED. 


ARSENIC. 

Arsenical  poisoning  is  fonnd  among  the  various  ar- 
tificers in  that  metal ;  also  among  those  who  use  fabrics 
containing  arsenic  in  the  dyes,  as  artificial  -  flower 
makers,  seamstresses,  and  paper-hangers.  Wall-papers, 
cretonnes,  etc.,  bring  others  in  contact  with  the  poison. 

Among  some  of  the  more  common  symptoms  are 
disorders  of  the  digestive  organs,  gastric  catarrh,  weak- 
ness of  the  eyes,  conjunctivitis,  and  cutaneous  erup- 
tions. A  condition  of  general  debility,  or  even  paraly- 
sis, anaemia,  and  nervous  weakness,  resembling  neu- 
rasthenia, can  sometimes  be  traced  to  waU-papers 
containing  arsenic. 

After  acute  poisoning  by  the  ingestion  of  large  doses 
of  arsenic,  when  the  gastro-intestinal  symptoms  are 
passing  off,  those  pertaining  to  the  nervous  system  ap- 
pear. There  is  first  pain  in  the  back  and  limbs,  accom- 
panied with  numbness  or  a  sleepy  sensation.  With 
this,  a  weakness  which  increases  progressively  till  there 
is  total  paralysis.  These  phenomena  occur  within  a 
week  or  two  after  the  poisoning.  Sensation  may  be 
almost  lost,  or  scarcely  impaired. 

Atrophy  of  the  affected  muscles  follows,  and  the 
reaction  of  degeneration  is  found.  The  patellar  tendon 
reflex  has  been  found  absent,  the  plantar  cutaneous 
reflex  absent,  while  the  cremaster  reflex  was  normal. 

The  paralysis  begins  in  the  legs,  and  is  most  severe 
in  them  ;  may  also  affect  the  arms,  usually  in  a  less  de- 
gree. 

Cutaneous  trophic  and  vaso-motor  changes  are  not 
infrequent.  In  some  cases  albumen  has  been  found  in 
the  urine. 

Generally,  improvement  begins  within  a  month,  and 
steadily  progresses  to  perfect  or  nearly  perfect  recov- 
ery ;  a  slight  weakness  may  remain  a  year  after  the 
poisoning.  In  a  few  cases  the  paralysis  may  be  per- 
manent. -  : 


TOXIC  NEUROSES.  395 

Seeligmuller  gives  several  diagnostic  points  :  1.  The 
acute  origin  of  the  paralysis  as  contrasted  with  the 
chronic  nature  of  lead  paralysis,  2.  The  severe  sen- 
sory disturbance.  3.  Arsenic  affects  primarily,  and 
most  frequently,  the  legs.  4.  Atrophy  and  reaction  of 
degeneration  appear  earlier  in  arsenical  poisoning.  5. 
Other  trophic  changes  are  not  seen  in  lead. 

The  evidence  is  sufficient  to  prove  that  the  symp- 
toms are  due  to  a  diffused  myelitis  affecting  especially 
the  anterior  gray  substance. 

TREATMEiSTT. — It  does  not  seem  to  be  certainly  as- 
certained that  any  special  medication  hastens  the  elimi- 
nation of  arsenic.  As  it  leaves  the  system  chiefly 
through  the  kidneys,  their  action  should  be  main- 
tained, as  well  as  that  of  the  skin,  by  baths  and  proper 
clothing. 

Morphia,  or  other  anodynes,  may  be  necessary  on 
account  of  the  pain. 

Electricity  and  massage  must  be  used  to  restore  the 
use  of  the  muscles,  as  in  other  affections  with  similar 
loss  of  power. 

ALCOHOL. 

The  symptoms  of  acute  alcoholism,  as  seen  in  sim- 
ple drunkenness,  need  not  be  described  here.  Those 
of  chronic  poisoning  vary  considerably.  The  more 
common  effects  are  a  gradually  undermining  of  the 
health  and  a  change  in  important  viscera,  as  liver  and 
kidney,  giving  rise  to  diseases  of  those  organs. 

The  most  common  nervous  disturbance  is  found  in 
that  condition  known  as  delirium  tremens.  This  is  the 
final  result  of  a  long  debauch.  Patients  vary  greatly 
as  to  the  ease  with  which  they  have  an  attack. 

It  is  the  common  belief  that  the  sudden  leaving  off 
of  drinking  is  the  cause  of  delirium  tremens.  Some- 
times this  is  so,  but  many  times  the  patient  gives  up 
the  liquor  because  he  can  not  take  it ;  the  system  wiU 
not  longer  tolerate  the  poison,  and  then  the  cessation 


396  UNCLASSIFIED. 

from  drinking  is  the  first  symptom  of  the  disease,  not 
the  cause  of  its  outbreak. 

Besides  the  influence  of  alcohol,  it  will  be  found 
that  there  has  been  abstinence  from  food  and  loss  of 
sleep,  aiding  to  produce  the  final  outbreak  of  delirium. 
In  severe  cases,  it  will  be  found  that  patients  have  not 
slept  for  a  week  or  more,  and  have  eaten  nothing  for 
several  days. 

Preceding  the  attack  there  is  a  tremor  of  the  hands, 
tongue,  and  sometimes  a  general  tremor  whenever  the 
limbs  are  moved.  Vomiting  may  appear  a  day  or  two 
before  the  delirium.  At  first  there  is  only  an  inclina- 
tion to  start  suddenly ;  there  is  a  watchfulness  in  the 
patient's  expression,  and  he  is  evidently  divided  in  his 
attention  to  the  physician  and  his  unexpressed  fears. 
He  fingers  the  bedclothes  with  trembling  hands.  Per- 
haps he  is  covered  with  a  cold  perspiration.  The  eyes 
are  red  and  watery  ;  he  has  a  haggard  exjoression. 
After  a  while  the  delirium  may  become  more  active ; 
various  hideous  and  repulsive  shapes  present  them- 
selves to  the  disordered  brain.  The  patient  starts  up, 
and  struggles  violently  to  escape  from  his  tormentors. 
Hallucinations  of  hearing  are  much  less  common  than 
those  of  sight. 

It  is  very  seldom  that  patients  ever  attempt  to  in- 
jure themselves  or  others.  If  attacks  are  made  upon 
attendants,  it  is  in  connection  with  some  hallucination, 
or  in  an  endeavor  to  escape  from  imaginary  specters. 
So,  also,  efforts  to  Jump  out  of  windows,  etc.,  are  made 
for  the  purpose  of  escape. 

The  temperature  varies  ;  it  is  often  normal,  is  some- 
times subnormal,  and  may  be  elevated.  It  is  almost 
impossible  to  take  the  temperature  in  an  excited  pa- 
tient. 

The  pulse  is  rapid  and  weak  where  there  is  much 
excitement,  or  it  may  be  only  slightly  increased  in  fre- 
quency when  the  excitement  is  moderate ;  it  ranges 
from  80  to  150,  or  even  more. 


TOXIG  NEUROSES.  397 

Disgust  for  food,  and  vomiting  of  everything  taken 
into  the  stomach,  are  quite  common. 

If  the  patient  does  not  obtain  sleep,  the  tremor, 
delirium,  feebleness  of  the  pulse,  and  general  prostra- 
tion increase  until  death.  N"ear  the  close  of  life  the 
temperature  may  rise  to  106°  or  107°. 

A  fatal  termination  is  rare  if  the  patient  is  seen 
early  and  properly  treated,  unless  there  is  organic  dis- 
ease of  one  of  the  important  organs. 

Instead  of  delirium  tremens,  or  after  an  attack,  the 
victims  of  alcoholism  may  have  serious  cerebral  symp- 
toms, resembling  meningitis,  or  there  may  be  organic 
disease  of  the  brain  ;  sometimes  there  is  insanity,  usu- 
ally mania,  often  general  paralysis.  The  prognosis  in 
such  cases  is  unfavorable. 

Teeat:\iext. — A  quiet  room  is  desirable,  with  as 
little  disturbance  from  attendants  as  may  be.  It  is 
better  in  some  cases  to  have  the  room  darkened ;  but 
many  times  the  uncertain,  fitful  shadows  in  a  dimly 
lighted  room  disturb  the  patient  more  than  a  bright 
light.  His  imagination  transforms  the  shadows  into 
grotesque  or  horrible  shapes. 

Some  authors  object  to  mechanical  restraint,  advis- 
ing that  there  should  be  attendants  enough  to  keep  the 
patient  quiet  and  prevent  his  injuring  himself  or  oth- 
ers. Those  who  need  restraint  are  excited  by  the  op- 
position of  other  men  ;  they  will  struggle  against  those 
who,  they  imagine,  are  about  to  injure  them.  If  put 
into  a  strait-jacket,  their  struggles  soon  cease,  or  are 
much  less  violent,  and  there  is  no  danger  of  injury  from 
too  great  force  applied  by  injudicious,  tired,  or  excited 
(not  angry)  attendants.  Of  course,  a  patient  in  a  strait- 
jacket  needs  to  be  watched  lest  he  should  work  himself 
into  a  dangerous  position,  or  roll  out  of  bed,  or  other- 
wise harm  himself.  If  there  is  vomiting,  tincture  of 
capsicum  should  form  a  part  of  every  prescription ; 
sometimes  it  is  sufficient  alone  to  produce  sleep,  and 
enable  the  stomach  to  retain  food. 


398  UNCLASSIFIED. 

If  the  pulse  is  very  rapid  and  weak,  if  there  is  much 
excitement  and  tremor,  that  is,  in  the  worst  cases, 
tincture  of  digitalis,  with  or  without  capsicum,  is  the 
best  drug.  According  to  the  pulse,  from  one  to  four 
drachms  should  be  given.  If  the  pulse  is  strong  and 
only  moderately  rapid,  one  drachm,  or  perhaps  half  a 
drachm,  will  be  sufficient.  In  very  severe  cases  the 
larger  doses  are  needed.  One  dose,  sufficient  to  strength- 
en the  pulse,  is  better  than  to  repeat  small  doses.  Sleep 
may  follow  in  half  an  hour.  The  digitalis,  not  in  the 
largest  doses,  may  be  repeated  after  twelve  or  twenty- 
four  hours  if  it  is  necessary  to  procure  sleep  again. 
Often  only  one  dose  is  required.  It  must  be  kept  in 
mind  that  the  patient  receives  considerable  alcohol  with 
large  doses  of  the  tincture. 

Chloral  and  bromide  of  potassium  are  valuable  in 
the  milder  cases,  and  in  the  severer  after  digitalis  has 
reduced  the  pulse.  One  or  two  large  doses,  thirty  to 
forty  grains  of  chloral,  with  as  much  bromide,  is  better 
than  repeating  small  doses  frequently.  The  latter  may 
increase  the  excitement.  If  the  stomach  is  very  irri- 
table, it  is  better  to  give  only  the  capsicum  by  the 
mouth  ;  chloral,  if  necessary,  can  be  given  by  enema. 

Paraldehyde,  in  drachm  doses,  may  be  sufficient  in 
very  mild  cases,  or  after  one  or  two  nights'  sleep  ob- 
tained by  other  means.  I  have  not  used  it  in  severer 
cases. 

Formerly  opium,  or  its  preparations,  were  generally 
used.  In  some  cases  the  hypodermic  injection  of  a 
quarter  of  a  grain  of  morphia  is  the  best  treatment. 

After  the  patient  has  become  quiet,  the  oxide  of 
zinc,  two  or  three  grains,  or  sulphate  of  quinine,  three 
to  five  grains,  given  three  times  a  day,  wiU  prove  most 
useful  tonics. 

It  is  important  that  the  patient  should  be  well  fed  ; 
at  first  milk,  hot  or  cold,  as  best  suits  the  patient,  or 
animal  broths,  are  best ;  when  the  stomach  will  digest 
solid  food,  it  should  be  given. 


TOXIC  NEUROSES.  399 


HYDROPHOBIA.. 


Hydrophobia  is  always  caused  by  the  bite  or  the  in- 
oculation with  the  saliva  of  a  rabid  animal.  It  never 
arises  spontaneously.  Domestic  animals,  dogs,  cats, 
cows,  etc.,  and  wild  animals,  as  foxes  or  wolves,  may 
communicate  the  disease. 

About  half  those  bitten  are  attacked  with  rabies ; 
bites  on  unprotected  parts,  hands,  face,  and  neck,  are 
most  dangerous.  Early  cauterization  of  the  wound 
diminishes  the  danger.  Slight  wounds,  like  scratches, 
are  more  likely  to  give  trouble  than  severe  bites  which 
bleed  freely. 

There  is  a  stage  of  incubation,  continuing  from  two 
weeks  to  five  years  (Colin),  during  which  the  wound 
heals,  the  patient  appears  in  usual  health,  though  often 
he  has  a  serious  apprehension,  a  dread  of  the  conse- 
quences, which  he  can  not  explain. 

Often  the  first  symptom  of  the  approaching  attack 
is  a  pain  shooting  from  the  seat  of  the  wound  toward 
the  nerve-centers ;  the  cicatrix  may  become  livid.  The 
patient's  disposition  may  show  a  change — ^he  may  be- 
come moody  or  irritable.  With  or  without  the  above 
symptoms  there  arises  a  peculiar  difficulty  in  swallow- 
ing. All  the  motions  can  be  made,  but,  so  soon  as  the 
liquid  or  food  touches  the  mucous  membrane  of  the 
mouth,  the  irregular  or  spasmodic  action  of  the  throat 
interferes  with  deglutition.  Generally,  speech  is  also 
hindered. 

At  first  the  patient  can  overcome  this  irregular  ac- 
tion of  the  muscles,  but  soon  he  loses  that  power,  and 
the  reflex  excitability  becomes  so  excessive  that  any 
noise  suggesting  food  or  drink  excites  the  spasm.  Oth- 
er regions  also  acquire  this  abnormal  excitability,  so 
that  a  slight  draught  of  air  over  the  face,  the  glitter  of 
a  bright  light  on  the  eye,  or  a  sharp  sound  heard,  has 
the  same  effect. 

The  patient  is  unable  to  swallow  his  saliva,  which 


400  UNCLASSIFIED. 

becomes  tMck,  tenacious,  and  ropy.  The  irritation 
thus  produced  gives  rise  to  violent  paroxysms  ;  the  pa- 
tient starts  up,  hurling  violently  back  his  attendants, 
clutches  at  his  throat,  tries  to  clear  his  mouth  of  the 
mucus,  and  spits  it  far  from  him  with  extreme  violence. 
His  whole  effort  seems  to  be  to  expel  the  saliva  which 
so  distresses  him  and  interferes  with  reflex  respiration. 

Delirium,  hallucinations,  and  delusions  are  some- 
times noticeable  during  these  paroxysms,  and  occasion- 
ally in  the  intervals. 

After  such  an  attack  the  patient  lies  quiet,  or  may 
sit  up  at  his  ease  ;  can  usually  walk  if  desirable.  He 
knows  when  the  attack  is  about  to  be  repeated,  and 
may  warn  his  attendants.  There  is  almost  never  any 
effort  to  bite  or  scratch.  The  stories  of  patients  bark- 
ing like  dogs,  etc.,  are  in  a  great  degree  the  products  of 
the  imagination  of  attendants. 

Finally,  these  paroxysms  become  more  and  more  fre- 
quent, the  patient  is  exhausted  by  his  inability  to  take 
food,  by  sleeplessness,  and  by  the  violence  of  the  dis- 
ease. Partial  paralysis  may  occur.  Death  takes  place 
either  during  an  attack  or  quietly  in  the  interval ;  the 
power  to  swallow  may  return  Just  before  death. 

The  imagination,  or,  perhaps,  it  would  be  more  cor- 
rect to  say  the  emotional  conditions  and  the  mental 
influences,  seems  to  exert  a  great  influence  over  the 
attacks.  The  sight  of  water,  even  a  reference  to  drink- 
ing, will  cause  one  ;  yet  the  same  patient  may  immedi- 
ately after  urinate,  both  seeing  the  urine  and  hearing 
it  fall  into  the  vessel  without  any  disturbance. 

Diagnosis  and  Prognosis.  —  The  only  affection 
likely  to  be  confounded  with  hydrophobia  is  hysteria, 
which  in  some  of  its  manifestations  slightly  resembles 
the  more  serious  disorder.  A  careful  observation  of 
the  patient's  condition  during  the  spasm,  and  in  the  in- 
terval, will  guide  to  a  diagnosis,  as  will  also  the  experi- 
ment of  gently  fanning  his  face,  or  the  manner  in  which 
he  acts  when  drink  is  offered,  bracing  himself  for  a 


TOXIG  NEUROSES.  401 

great  effort,  seizing  tlie  cup,  unable  to  carry  it  to  his 
mouth,  or  only  succeeding  in  swallowing  a  few  drops  ; 
the  character  of  the  attack  is  very  different  from  hys- 
teria. 

There  is  no  resemblance  to  tetanus,  as  has  been 
sometimes  claimed. 

Hitherto  death  has  been  the  uniform  termination, 
except  in  a  few  cases,  and  in  many  of  these  the  diag- 
nosis is  doubtful. 

Pathological  Anatomy. — The  blood-vessels  of  the 
brain  and  spinal  cord  are  distended,  their  walls  are 
thickened,  and  in  many  places  collections  of  leucocytes 
surround  the  smaller  vessels,  and  they  may  be  found 
quite  generally  scattered  through  the  gray  substance. 
Sometimes  the  blood  escapes  from  the  vessels,  forming 
small  haemorrhages.  Ross  has  found  the  nerve-cells  of 
the  median  and  central  groups  in  the  anterior  cornua 
shrunken  and  atrophied  ;  the  spinal  accessory  and  pneu- 
mogastric  nuclei  were  also  altered. 

Treatmeistt. — As  soon  as  one  has  been  bitten  by  a 
dog,  whether  thought  to  be  rabid  or  not,  the  wound 
should  be  sucked,  either  by  the  person  himself  or  by 
some  one  else.  If  the  mucous  membrane  of  the  mouth 
is  unbroken,  there  is  no  danger  in  doing  this.  As  soon 
as  possible  after  this  the  wound  should  be  thoroughly 
cauterized.  Some  advise  nitrate  of  silver,  others  caus- 
tic potash  ;  the  latter  is  probably  the  better.  The  hot 
iron  may  answer  the  same  purpose,  but  is  less  certain 
in  its  effect,  as  it  can  not  so  surely  penetrate  to  every 
part  of  the  cavity.  Gunpowder  may  be  poured  into 
or  upon  the  wound  and  ignited.  Or  the  wound  may  be 
excised. 

When  the  first  symptoms  of  the  disease  have  shown 
themselves,  there  is  little  chance  of  recovery.  Chloral, 
morphia,  and  stimulants  given  by  the  rectum  may  re- 
lieve the  suffering  somewhat.  Ether  can  be  inhaled  to 
give  relief,  and  while  the  patient  is  under  its  influence 
a  tube  may  be  passed  into  the  stomach  and  food  intro- 

26 


402  UNCLASSIFIED. 

duced.  Curare  and  morphia  can  be  injected  subcu- 
taneously.  Ruxton  gave  six  drops  of  tincture  of  can- 
nabis Indica  to  a  boy  about  six  years  old  eacli  time  lie 
awoke.  The  boy  recovered.  Broadbent  reports  a  cure 
from  enemata  of  twenty  grains  of  chloral,  one  ounce 
of  brandy,  and  two  ounces  of  beef -jelly  every  three 
hours. 


CHAPTER  XXXYI. 

SYPHILIS. 

Zambaco,  D.  a.,  Des  affections  nerveuses  syphilitiques.  Paris, 
1862. — Heubner,  Die  luetische  Erkrankung  der  Hirnarterien. 
Leipzig,  1874. — FoURNiER,  A.,  La  syphilis  du  cerveau.  Paris, 
1879. — Savard,  p.,  Etude  sur  les  myelites  syphilitiques.  Paris, 
1881.— Wood,  H.  C.  Am.  Jour.  Med.  Sci.,  Oct.,  1880,  p.  384  ; 
Boston  Med.  and  Surg.  Jour.,  Dec.  20,  1883,  Jan.  10,  Feb.  28, 
1884. — Lancereaux,  E.,  Syphilis  cerebral.  Gaz.  hebd.,  1882. — 
PuTZEL,  L.,  Syphilis  of  the  Central  Nervous  System.  Med.  Rec- 
ord, April  26,  1884,  p.  450.— Seguin,  E.  C,  The  American  Method 
of  giving  Potassium  Iodide,  etc.    Archives  of  Med.,  Oct.,  1884. 

Syphilis  of  the  nervous  system  belongs  to  the  ter- 
tiary period.  The  first  symptoms  may  appear  as  early 
as  two  months  after  infection,  or  as  late  as  thirty  years ; 
generally  between  three  and  twenty  years  after. 

The  nervous  symptoms  are  much  more  frequently 
seen  after  a  very  mild  primary  attack,  and  in  a  large 
proportion  of  cases  there  have  been  no  secondary  symp- 
toms. So  slight  has  been  the  earlier  manifestations  of 
the  disease  that  the  patient  frequently  does  not  know 
he  has  had  it. 

SYPHILIS  OF  THE  BRAIN. 

PATHOLoaic  AL  AxATOMY. — The  changes  in  the  brain 
are  similar  to  those  found  elsewhere.  The  membranes 
and  vessels  are  most  frequently  affected.  Gummatous 
tumors  form  in  the  membranes,  varying  in  size  from 
small  grains  to  the  size  of  a  hen's  egg ;  they  are  most 
frequent  in  the  pia  mater.  They  are  found  on  the  con- 
vexity, and  especially  at  the  base  near  the  sella  turcica. 


404:  UNCLASSIFIED. 

Instead  of  distinct  tumors,  there  may  be  a  diffusion 
of  the  new  growth  over  the  surface  of  the  membranes 
closely  resembling  pus,  and  this  may  contain  small 
gummatous  tumors  scattered  throughout  its  extent. 

The  subjacent  cerebral  substance  is  necessarily  af- 
fected, partly  by  spread  of  the  growth  destroying  the 
nerve-elements,  in  part  by  closure  of  blood-vessels,  in- 
terfering with  nutrition. 

The  syphilitic  new  growths  may  undergo  degenera- 
tion, and  their  interior  become  fatty  or  caseous.  They 
may  excite  inflammation  in  their  vicinity,  acting  as  any 
other  new  growth  in  this  respect. 

The  arteries  are  also  the  seat  of  syphilitic  changes. 
These  have  been  described  at  length  by  Heubner.  The 
new  growth  is  developed  between  the  elastic  lamina  of 
the  intima  and  the  endothelium.  The  lumen  of  the 
vessels  is  more  or  less  encroached  upon  by  semi-lunar 
segments  or  zones  of  the  firm,  fibrous  new  formation. 
Sometimes  the  artery  is  entirely  closed  by  this  process, 
or  a  thrombus  may  form  at  the  constricted  portion,  and 
thus  finally  effect  its  closure. 

The  brain-substance  may  be  primarily  affected ;  but 
such  cases  are  rather  rare. 

An  important  peculiarity  of  syphilitic  lesions  of  the 
brain  and  its  membranes  is  that  they  are  very  often 
multiple  ;  even  distant  regions,  opposite  sides,  may  be 
simultaneously  affected.  They  may  be  present  an  in- 
determinate period,  and  attain  considerable  size,  with- 
out giving  rise  to  any  symptoms. 

Secondary  changes,  softenings,  and  inflammations 
are  found  in  connection  with  these  morbid  products, 
the  same  as  with  those  of  a  different  nature. 

Symptoms. — Syphilis  of  the  nerve-centers  gives  rise 
to  no  special  or  peculiar  symptoms  differing  from  those 
caused  by  other  lesions  of  those  parts.  The  diagnosis 
must  be  made  rather  from  the  grouping  of  the  symp- 
toms or  other  peculiarities  in  the  mode  in  which  they 
show  themselves.     As  in  other  diseases,  the  symptoms 


SYPHILIS.  405 

may  be  divided  into  those  whicli  are  due  directly  to 
tlie  lesion  and  those  which  are  dependent  upon  sec- 
ondary changes,  which  are  the  same  as  when  these 
changes  are  due  to  other  causes. 

Headache  is  the  most  common  and  the  earliest 
symptom,  often  the  only  one.  The  pain  is  severe,  ob- 
stinate, frequently  nocturnal ;  it  occurs  in  paroxysms, 
though  there  may  not  be  entire  relief  between  the  at- 
tacks. The  scalp  or  parts  of  the  face  may  be  tender, 
and  pressure  upon  those  points  may  aggravate  the  pain. 
The  severity  of  the  pain  is  sometimes  excessive — ago- 
nizing. Relief  is  obtained  generally  only  from  specific 
treatment ;  or,  if  it  seems  to  follow  other  means,  the 
pain  soon  returns.  Sometimes  external  periostitis  will 
cause  a  swelling  over  the  cranial  bones,  which  will  set- 
tle the  diagnosis. 

Pain  may  also  be  felt  in  other  parts  of  the  body,  in 
the  limbs,  resembling  closely  neuralgia  from  other 
causes. 

With  the  pain,  or  independently,  the  patient  may 
have  a  sense  of  pressure  in  the  head,  dizziness  or  ver- 
tigo, ephemeral  or  fugitive  attacks  of  loss  of  memory, 
dimness  of  sight,  numbness  in  the  extremities,  or  slight 
impairment  of  motor  power  or  of  speech.  These  symp- 
toms may  be  so  insignificant  that  they  are  ignored  until 
questions  recall  them  to  the  patient's  mind. 

The  headache,  with  or  without  the  above  symptoms, 
is  of  inestimable  value  as  indicating  commencing  cere- 
bral mischief  at  a  stage  when  treatment  can  be  of  use. 
Though  a  similar  train  of  phenomena  may  occur  in 
cases  of  tumor  of  the  brain,  in  urgemia,  and  in  com- 
mencing meningitis,  the  possibility  of  syphilis  should 
always  be  kept  in  mind,  even  when  patients  deny  the 
primary  or  secondary  symptoms. 

The  motor  phenomena,  paralysis  and  spasm,  are 
characterized  by  the  irregularity  of  the  symptoms,  the 
limitation  of  the  paralysis  or  spasm  to  a  few  muscles, 
and  their  ephemeral  or  fugitive  character. 


406  UNCLASSIFIED. 

Hemiplegia,  differing  in  notliing  from  that  caused 
by  cerebral  lisemorrliage,  may  occur  without  special 
warning  in  syphilis  ;  but  generally  the  attack  is  less 
sudden,  the  paralysis  creeping,  as  it  were,  from  one  set 
of  muscles  to  another,  the  patient  not  losing  conscious- 
ness ;  the  loss  of  power  frequently  does  not  affect  the 
whole  side ;  is  limited  to  the  arm  or  face,  or  spares  the 
leg.     Sensibility  is  rarely  affected. 

Attacks  of  paralysis  of  a  few  muscles  or  sets  of  mus- 
cles mnj  appear  and  disappear  several  times  before 
there  is  permanent  loss  of  power ;  these  attacks  may 
persist  a  few  hours  or  days,  and  be  repeated  at  near  or 
distant  intervals. 

Spasm,  local  or  general,  sometimes  precedes  the  pa- 
ralysis. 

When  the  prodromic  cephalalgia,  and  other  slight 
cerebral  disturbances,  mentioned  above,  have  preceded 
these  paralytic  symptoms,  there  is  great  reason  to  sus- 
pect syphilis,  and  the  proper  treatment  should  be  fol- 
lowed. 

When  individual  cerebral  nerves  are  affected,  as 
well  as  the  limbs,  if  the  symptoms  are  irregular,  can 
not  be  accounted  for  by  one  lesion,  the  alternate  pa- 
ralysis being  such  as  to  show  that  there  must  be  two  or 
more  centers  of  disease,  the  probability  of  syphilis  is 
greatly  increased. 

Among  the  cranial  nerves  most  likely  to  be  para- 
lyzed may  be  placed,  first,  the  third  nerve,  the  motor 
oculi;  the  sixth,  the  abducens,  is  next;  the  seventh, 
twelfth,  the  second,  eighth,  and  fifth  follow  next  in 
frequency. 

Paralysis  of  the  third  nerve  from  syphilis  is  often 
partial ;  it  may  be  combined  with  paralysis  of  the  sixth 
or  not;  whether  alone  or  in  connection  with  disturb- 
ance of  other  cranial  nerves,  there  is  reason  in  such 
cases  to  suspect  syphilis,  and  careful  inquiry  for  pro- 
dromic symptoms  may  add  to  this  probability. 

It  is  unnecessary  to  describe  minutely  all  the  vari- 


SYPHILIS.  407 

ous  combinations  wMcli  are  frequently  found  in  such 
cases. 

Spasm  or  convulsion  limited  to  a  few  muscles,  as  the 
facial,  or  those  of  one  arm,  of  the  hand — monospasm, 
as  it  is  called — is  an  indication  of  irritation  of  the  motor 
centers  in  the  cortex  of  the  brain.  Very  often  the  le- 
sion in  these  cases  is  syphilitic.  The  convulsion  may 
extend  to  the  whole  of  one  side,  or  it  may  begin  in  one 
region  and  extend  to  the  opposite  side,  becoming  gen- 
eral. Many  times  consciousness  is  preserved,  or  it  may 
be  only  partially  impaired.  Sometimes  severe  pain 
in  the  head  or  in  the  affected  limb  may  attend  the 
spasm. 

Convulsions,  differing  in  no  respect  from  true  epi- 
lepsy, may  be  due  to  syphilis.  If  the  patient  is  some- 
what advanced  in  age  before  the  attacks  commence, 
their  syphilitic  origin  is  the  more  probable.  If  mental 
impairment  appears  early,  and  motor  weakness  follows 
the  attacks,  limited  to  one  side  or  one  limb,  and  per- 
sisting between  the  attacks,  the  probability  of  syphilis 
is  the  greater. 

Sometimes  the  mental  phenomena  are  most  promi- 
nent ;  intellectual  weakness,  loss  of  memory,  inability 
for  consecutive  thought,  delirium,  perhaps  mania,  may 
be  present.  Sometimes  the  mental  disturbance  will 
closely  resemble  general  paralysis. 

While  the  above  symptoms,  or  groups  of  symptoms, 
individually  only  give  rise  to  a  suspicion  of  syphilis, 
the  combination  of  two  or  more  of  the  groups  increases 
the  certainty  of  the  diagnosis. 

The  course  of  cerebral  syphilis,  if  not  properly 
treated,  is  steadily  downward.  The  symptoms  increase 
in  severity,  the  spasms  become  more  frequent,  the  pa- 
ralysis extends,  and  the  mental  powers  are  gradually 
lost.  Within  a  comparatively  short  time  a  fatal  termi- 
nation closes  the  scene. 


408  UNCLASSIFIED. 

SYPHILIS  OF  THE  SPINAL  CORD. 

The  membranes  are  most  frequently  tlie  seat  of  the 
morbid  changes,  the  cord  being  affected  secondarily. 
Sometimes  the  medullary  substance  itself  is  attacked, 
the  lesion  being  generally  diffused  throughout  the  part 
of  the  cord  which  is  the  seat  of  the  disease.  Gumma- 
tous tumors  are  also  found.  The  bones  are  less  fre- 
quently diseased.  The  lumbar  enlargement  is  more 
generally  attacked  than  the  higher  parts. 

The  symptoms  are  very  similar  to  those  produced 
by  other  lesions.  When  meningitis  is  present  there 
are  pains  in  the  back  and  limbs,  perhaps  with  spas- 
modic action  or  contraction.  The  symptoms  are  vari- 
able ;  there  may  be  remissions  or  intermissions,  which 
are  not  seen  in  simple  meningitis. 

When  the  cord  itself  is  affected  there  is  more  likely 
to  be  irregularity  in  the  course  of  the  disease  than  in 
simple  myelitis.  Locomotor  ataxia  may  be  very 
closely  simulated.  The  earlier  symptoms  may  relate 
to  the  genito-urinary  organs.  Impotence  and  inability 
to  micturate  may  precede  the  paralysis.  When  the 
latter  appears,  it  may  begin  in  one  leg,  and  appear  in 
the  other  later. 

Sensation  may  be  unaffected  until  the  paralysis  has 
become  well  marked  ;  it  may  be  only  slightly  disturbed 
during  the  whole  course  of  the  disease.  In  other  cases 
both  sensation  and  motion  may  be  lost  early.  Some- 
times the  paralysis  pursues  an  acute  course  very  simi- 
lar to  the  severest  form  of  ordinary  acute  myelitis. 

Often  the  course  of  spinal  syphilis  is  chronic ;  the 
symptoms  develop  slowly  ;  there  may  be  periods  of  re- 
mission, or  at  least  no  advance  is  made. 

The  prognosis  is  unfavorable  for  complete  recovery ; 
if  energetic  treatment  is  followed,  the  symptoms  may 
recede  and  a  certain  amount  of  benefit  be  received  ;  the 
patient  improves,  but  very  often  the  cord  is  too  serious- 
ly injured  for  its  functions  to  be  completely  restored. 


SYPHILIS.  409 


SYPHILIS  OF  THE  NERVES. 

The  cranial  nerves  are  tlie  most  frequently  affected 
by  syphilis ;  these  have  been  referred  to  already.  Any 
of  the  other  nerves  may  be  implicated  in  syphilitic 
growths.  It  is  probable  that  the  nerves  may  be  direct- 
ly diseased ;  many  cases  of  neuralgia  in  syphilitic  pa- 
tients are  probably  thus  caused.  The  symptoms  seem 
to  be  very  similar  to  those  of  neuritis.  This  depart- 
ment of  the  subject  needs  further  investigation. 

Hereditary  syphilis  may  attack  the  nerve-centers ; 
cerebral  symptoms  are  not  uncommon ;  the  spinal  cord 
has  been  the  seat  of  syphilitic  changes  in  very  young 
children. 


TREATMENT  OF  SYPHILIS  OF  THE  NERVOUS  SYSTEM. 

There  should  be  no  delay  in  beginning  an  anti- 
syphilitic  treatment.  The  more  serious  the  symptoms, 
the  more  energetic  this  should  be.  As  the  brain  and 
spinal  cord  are  all-important  for  life,  and  as  slight 
lesions  produce  serious  permanent  disability,  it  is 
necessary  to  begin  at  once  with  large  doses  of  iodide  of 
potassium,  and  to  use  mercury  freely. 

If  the  case  is  very  urgent,  from  forty  to  sixty  grains 
can  be  given  at  once  three  times  a  day  ;  if  less  haste  is 
needed,  a  dose  of  ten  to  twenty  grains  may  be  given 
three  times  the  first  day ;  the  doses  may  be  increased 
by  ten  or  twenty  grains  each  day,  or  every  other  day, 
until  some  result  is  obtained. 

Large  doses  of  forty-five  to  sixty  grains  are  some- 
times borne  better  by  patients  than  small  doses  of  four 
or  five  grains. 

The  dose  should  be  increased  until  the  disease  is 
checked,  or  there  is  evident  intolerance.  What  is  the 
limit  ?  Many  patients  improve  when  taking  one  hun- 
dred and  twenty  grains  a  day.  I  have  repeatedly  given 
two  hundred  and  fifty  grains  daily,  and  have  even  gone 


410  UNCLASSIFIED. 

as  high,  as  nine  hundred  grains  a  day  with  no  disadvan- 
tage to  the  patient. 

The  drug  should  be  given  in  a  large  amount  of  wa- 
ter ;  slightly  alkaline  water  is  preferable.  It  is  gener- 
ally better  to  give  it  before  meals,  though  with  some 
patients  it  is  better  after  meals,  and  some  prefer  to  di- 
vide the  large  doses,  taking  part  before  and  part  after 
meals. 

If  the  bowels  become  too  loose  from  the  iodide,  the 
dose  may  be  slightly  reduced,  more  diluted,  and  then 
increased  more  slowly  ;  or,  if  there  is  need  for  immedi- 
ate effect,  a  few  drops  of  laudanum  can  be  added  to 
each  dose. 

Vomiting  may  seriously  interfere  with  the  adminis- 
tration of  the  drug.  If  it  does,  it  wiU  be  necessary  to 
omit  it  for  a  while,  then  begin  in  smaller  doses  and  in- 
crease more  slowly.  Or  the  plan  of  giving  a  large  dose 
at  once  might  be  tried. 

Conjunctivitis,  coryza,  and  glossitis  are  rare  in 
syphilitic  patients  as  effects  of  the  iodide. 

Acne  may  be  met  with  Fowler's  solution,  but  is  not 
a  contra-indication  to  the  use  of  the  medicine. 

Mercury  may  be  given  by  inunction,  half  a  drachm 
or  two  drachms  being  rubbed  in  daily.  Internally,  the 
biniodide  or  bichloride  is  preferable,  and  should  be 
given  in  doses  of  from  ^^^  to  ^  of  a  grain  three  times 
a  day.    Many  authorities  prefer  the  inunction. 

The  iodide  of  potassium  and  mercury  should  not  be 
stopped  too  soon.  It  is  necessary  to  continue  the  treat- 
ment several  weeks  after  the  patient  seems  cured.  The 
largest  dose  reached  need  not  be  continued. 

Of  other  treatment,  tonics,  especially  iron  and  cod- 
liver  oil,  are  generally  indicated.  The  strength  should 
be  maintained  by  a  generous  diet. 

Sequelae  and  complications  should  be  treated  accord- 
ing to  the  principles  given  elsewhere. 


INDEX. 


Abscess  of  the  brain,  134. 

Acute  ascending  paralysis,  193. 

-Slsthesiometer,  method  of  using,  3. 

Agrammatism,  48. 

Agraphia,  47. 

Akataphasia,  48. 

Alcoholism,  395. 

Amaurosis  in  cerebral  lesion,  41. 

Amblyopic  cerebral  lesion,  41. 

Amimia,  47. 

Amyotrophic  lateral  sclerosis,  353. 

Anaemia  of  brain,  68. 

acute,  70. 

chronic,  71. 
Anaesthesia,  3. 
Anarthria,  47, 

in  lesion  of  the  pons,  45. 

locality  of  lesion  in,  49. 
Angina  pectoris,  318. 
Ankle  clonus,  9. 

in  lesion  of  spinal  cord,  144. 
Aphasia,  amnesic,  46. 

ataxic,  47. 

locality  of  lesion  in,  48. 
Apoplexy,  86. 

in  multiple  sclerosis,  346. 
Arsenic  poisoning,  394. 
Arthralgia,  lead  poisoning,  391. 
Asphyxia,  local,  of  the  limbs,  333. 
Ataxia,  46,  141. 

hereditary,  836. 

locomotor,  334. 
Athetosis,  98. 

seat  of  lesion  in,  39. 
Atrophy,  facial,  324. 

muscular,    in   disease    of   spinal 
cord,  139. 
Atrophy,  muscular,  progressive,  207. 

Backache,  148. 
Basedow's  disease,  316. 
Bed-sores,  treatment,  10. 
Beri-beri,  366. 
Blepharospasm,  300. 


Brain,  abscess,  124. 

anaemia,  68. 

anatomy,  18. 

arteries,  anastomoses,  33. 

blood-vessels,  31. 

convolutions,  nomenclature,  18-31. 

change  of  blood-supply,  68. 

congestion,  74. 

diseases  of,  15. 

exhaustion  in  cerebral  hyperaemia, 
77. 

haemorrhage,  84. 

hyperaemia,  74. 

lesions,  destructive,  37. 

lesions,  irritative,  37. 

malnutrition  (see  anemia),  69. 

membranes,  diseases  of,  50. 

motor  centers,  33. 

physiology,  33. 

sensory  centers,  34. 

symptomatology,  general,  37. 

syphilis,  403. 

tumors,  116. 

vessels   in  cerebral  haemorrhage, 
87. 

visual  centers,  35,  37. 
Bright's  disease  in  meningitis,  69. 
Bronchial  crises,  833. 
Bulbar  paralysis,  315, 

acute,  823. 

and  muscular  atrophy  compared, 
319. 

of  cerebral  origin,  823. 
Burdach,  column  of,  135. 

Caries  of  vertebrae,  167. 
Carrefour  sensitif ,  lesion  of,  39. 
Caudate  nucleus,  31. 

functions,  37. 

lesion  of,  39. 
Cavities  in  brain  from  thrombosis, 

113. 
Centrum  ovale,  19. 
Cephalalgia,  307. 


412 


INDEX. 


Cerebellar  peduncle,  lesion  of,  46. 
Cerebellum,  hgemorrhage,  46. 

lesion  of,  46. 

tumor,  46. 
Cerebral  abscess,  124. 

anemia,  68. 
Cerebral  arteries,  occlusion  of,  107. 

thrombosis  of,  113. 
Cerebral  haemorrhage,  84,  86. 

diagnosis  from  embolism,  110. 

explanation  of  phenomena,  95. 

hyperasmia,  74. 

sequelae,  97. 

softening  in  embolism,  108. 

tumors,  116. 
Cerebro-spinal  sclerosis  (see   multi- 
ple sclerosis),  242. 
Cheyne-Stokes  respiration,  10. 
Chorea,  332. 
Chorea,  post-hemiplegic,  98,  335. 

seat  of  lesion  in,  39. 
Clonic  spasm,  299. 
Clonus,  ankle,  9. 

wrist,  9. 
Compression  of  spinal  cord,  167. 
Compulsory  movements,  46. 
Constipation,  treatment,  11. 
Contractures  after  cerebral  haemor- 
rhage, 97. 
Convolutions    of    brain    described, 

18. 
Corona  radiata,  19. 
Corpus  geniculatum,  origin  of  optic 

tract,  27. 
Corpus  quadrigeminum  anterior,  le- 
sion, 43. 

origin  of  optic  tract,  27. 

posterior,  lesion,  43. 

striatum,  nutrient  arteries,  32. 
Cramp,  professional,  304. 
Crus  cerebri,  basis,  22. 

division  of  fibers  in  basis,  23. 

lesion  of,  42. 

tegmentum,  22, 
Cystitis,  11. 

Degeneration,  descending,  course  of, 

23,  40. 
secondary,  in  lesion  of    internal 

capsule,  40. 
Delirium  tremens,  395. 
Diet,  13. 

Diphtheritic  paralysis,  295. 
Diplegic  contraction,  211. 
Diplopia,  3. 
Disseminated  neuritis,  266. 

sclerosis,  242. 
Dura    mater,  inflammation  of  (see 

pachymeningitis),  50. 


Dynamometer,  5. 
Dysarthria,  47. 

Eclampsia  saturnina,  392. 
Electricity,  changes  in  reaction  to,  5. 

in  testing  muscular  power,  5. 
Embolism  of  cerebral  arteries,  107. 
Emotions  in  cerebral  haemorrhage, 

99. 
Encephalopathia  saturnina,  392. 
Epilepsy,  342. 

diagnosis    from    cerebral    hyper- 
aemia,  80. 
Exophthalmic  goitre,  316. 
Byes,  conjugate  deviation,  44. 

examination  of,  45. 

Face,  atrophy  of,  324. 
Facial  nucleus,  lesion  of,  217. 
Feeding,  methods  of,  13. 

by  rectum,  14. 
Fibrillary  contractions,  210. 
Front  tap  contraction,  9. 

Gangrene,  symmetrical,  323. 
Gastric  crises,  231. 
Girdle  sensation,  147 
Goitre,  exophthalmic,  316. 
Goll,  columns  of,  134. 
Grand  mal,  344. 
Graves's  disease,  316. 

Hsematomyelitis,  162. 
Haematorrhachis,  159. 
Haemorrhage,  meningeal,  84. 

into  spinal  cord,  162. 

spinal  meningeal,  159. 
Headache,  307. 
Hemianopsia,  4. 

as  localizing  lesion,  41. 

lateral  homonymous,  41. 

nasal,  41. 

temporal,  double,  41. 
Hemiopia,  4. 

Hemiplegia,  pretended,  101. 
Hereditary  ataxia,  226. 
Hydromyelus,  176. 
Hydrophobia,  399. 
Hyperaemia  of  the  brain,  74. 
Hypertesthesia,  3,  147. 
Hypoglossal  nucleus,  lesion  of,  216. 
Hysteria,  353. 
Hystero-epilepsy,  360. 

Infantile  paralysis,  195. 
Internal  capsule,  20. 

course  of  fibers  leading  from,  28. 

fibers,  order  of,  36. 

lesion  of,  40. 


INDEX. 


413 


Internal  capsule,  sensory  fibers,  36. 
Island  of  Reil,  lesion  of,  48. 

Kak-ke,  266. 

Labio-glosso-laryngeal  paralysis,  215. 
Landry's  paralysis,  192. 
Laryngeal  crises,  232. 
Lateral  sclerosis,  250. 
Lead  colic,  390. 

poisoning,  390. 

poisoning  in    myelitis,   180,   188, 
891. 
Lenticular  nucleus,  21. 

functions,  37. 

lesion  of,  39. 
Leptomeningitis  cerebralis,  53. 

spinalis,  152. 
Local  asphyxia  of  the  limbs,  322. 
Locked-jaw,  379. 
Locomotor  ataxia,  224. 

Mania  in  cerebral  anaemia,  72. 

a  potu,  395. 
Megrim,  311. 
Meniere's  disease,  380. 
Meningeal  haemorrhage,  cerebral,  84. 

spinal,  159. 
Meningitis,  cerebral,  50. 

cerebral,  chronic,  58. 

cerebral,  local,  58. 

spinal,  149. 

tubercular,  61. 
Micturition,  disturbed,  in  disease  of 

spinal  cord,  144. 
Migraine,  811. 

Monospasm  in  meningitis,  58. 
Motion,  accelerated,  141. 

retarded,  141, 
Motor  centers,  lesion  of,  38. 

spasm  in  lesion  of,  38. 
Motor  power,  methods  of  testing,  5, 
Multiple  neuritis,  266. 

sclerosis,  242. 
Muscles  supplied  by  motor  nerves, 

140. 
Myelitis,  179. 

acute,  179. 

of  anterior  comua,  195. 

of  anterior  cornua  in  adults,  199. 

chronic,  188. 

from  lead,  391. 
Myxcsdema,  386. 

Nephritic  crises,  231. 
Nerve,  eighth,  origin,  31. 

fourth,  connection  with  sixth,  28, 
80. 

fourth,  origin,  28. 


Nerve,  seventh,  origin,  29. 

sixth,  origin,  29. 

sixth,  paralysis  of,  in    lesion  of 
pons,  45. 

third,  connections  with  sixth,  28, 
80. 

third,  nucleus,  lesion  of,  43. 

third,  origin,  27. 

third,  disease  of,  259. 
Nerves  of  medulla,  81. 

peripheral,  distribution  to  muscles, 
140. 

syphilis  of,  409. 
Nervous  exhaustion,  371. 

cause  of  ansemia  of  brain,  69. 
Neuralgia,  ceryico-brachial,  275. 

cervico-occipital,  274. 

dorso-intercostal,  275. 

lumbo-abdominai,  276. 

sciatica,  276. 

trifacial,  274. 
Neurasthenia,  871. 
Neuritis,  261. 

multiple,  266. 
Nutrition,  12. 

Ophthalmoscope,  importance  of,  4. 
Optic  chiasma,  decussation  in,  26. 
Optic  nerves,  26. 

neuritis,  in  cerebellar  lesion,  46. 

neuritis,  in  myelitis,  185. 

neuritis,  in  tumor  of  brain,  119. 

thalamus,  22. 

thalamus,  function,  37. 

thalamus,  lesion  of,  89. 

thalamus,  nutrient  arteries,  32. 

tract,  26. 

tract,  central  origin,  27. 

Pachymeningitis,  50. 

cervical  hypertrophic,  149. 

external,  50. 

internal  h?emorrhagic,  51. 

spinalis  externa,  149. 

spinalis  interna,  149. 
Painful  points,  272. 
Paralysis,  acute  ascending,  192. 

after  acute  diseases,  294. 

after  diphtheria,  294. 

agitans,  329. 

alternate,  43. 

brachial  plexus,  293. 

bulbar,  215. 

facial,  289. 

from  pressure,  285,  293. 

infantile,  195. 

Landry's,  192, 

lead,  391, 

local,  285. 


414 


INDEX. 


Paralysis  of  motion,  significance  in 
disease  of  spinal  cord,  139. 

ocular  muscles,  289. 

peripheral,  285. 

pseudo-hypertrophie,  255. 

reflex,  286. 

rheumatic,  285. 

seventh  nerve,  289. 
Paraphasia,  48. 
Parkinson's  disease,  339. 
Petit  mal,  344. 
Photopsia,  42, 

Pia  mater,  inflammation  of,  53. 
Points  apophysaires,  272. 

douloureux,  272. 

painful,  272. 
Poisoning,  arsenic,  394. 

lead,  390. 
Poliomyelitis,  anterior  acute,  195. 
in  adults,  199. 
in  infants,  195. 

anterior  chronica,  202. 
Pons  Varolii,  lesion,  44. 

sensation  in  lesion  of,  45. 
Post-hemiplegie  chorea,  335. 
Professional  cramp,  304. 
Progressive  muscular  atrophy,  207. 

hereditary,  212. 

juvenile  form,  212. 
Prosopalgia,  274. 

Pseudo-hypertrophic  paralysis,  255. 
Pseudo-meningitis  in  children,  73, 
Pulvinar,  function  of,  37. 

lesion  of,  41,  42. 
Pupil,  contracted,  in  lesion  of  pons, 
45. 

changes  in,  4. 

reaction  in  cerebral  lesion,  42. 
Pyramidal  columns,  135. 

Keaction  of  degeneration,  6. 
Reflex  action  described,  6. 

in  lesion  of  spinal  cord,  142. 

centers  in  spinal  cord,  8. 
Reflexes,  cutaneous,  7. 

deep,  8. 

patella  tendon,  8. 

tendon,  8. 
Respiration,  Cheyne-Stokes,  10. 
Retarded  motion,  141. 

Saint  Vitus's  dance,  332. 
Sciatica,  276. 
Sclerosis,  242. 

amyotrophic  lateral,  252. 

lateral,  250. 

multiple,  242. 

posterior  spinal,  224. 
Sensation,  changes  in,  3. 


Sensation  changes,  lesion  of  spinal 

cord,  147. 

methods  of  testing,  1. 

in  unilateral  lesion  of  spinal  cord, 
147. 
Sense,  muscular,  testing,  3. 

of  pain,  testing,  2. 

of  pressure,  testing,  2. 

of  temperature,  testing,  2. 

of  touch,  testing,  1. 
Sensory  fibers,  course  of,  36. 

in  pons,  45. 
Sexual  function  perverted  in   dis- 
ease of  spinal  cord,  145. 
Shaking  palsy,  339. 
Sick  headache,  311, 
Sleeplessness  in  anaemia  of  brain,  74. 
Spasm,  298. 

facial,  299. 

of  diaphragm,  303. 

symptom  of  lesion  of  motor  cen- 
ters, 38. 

symptom  of  lesion  of  spinal  cord, 
129. 
Speech,  disturbance  of,  46, 

in  lesion  of  pons,  45. 
Spinal  anaemia,  158, 
Spinal  cord,  anaemia  of,  158. 

anatomy,  132, 

blood-vessels,  133. 

cavities  in,  176. 

central  canal  dilated,  176. 

changes  in  blood-supply,  156. 

compression,  167. 

general  symptomatology,  138. 

gray  matter,  133. 

groups  of  cells,  133. 

haematorrhachis,  159. 

hsemorrhage,  162. 

hypereemia,  156. 

inflammation,  179. 

length,  133. 

membranes,  132. 

meningeal  haemorrhage,  159. 

physiology,  136, 

pia  mater,  inflammation  of,  152. 

sclerosis  of  lateral  columns,  250. 

sclerosis  of  posterior  columns,  224. 

slow  compression,  167. 

symptomatology,  138. 

syphilis,  408. 

unilateral  lesion,  motion  in,  139. 

unilateral  lesion,  sensation  in,  147. 

white  substance,  134. 
Spinal   dura   mater,    inflammation, 
149. 

hypersemia,  156. 

irritation,  373. 
1      leptomeningitis,  152. 


INDEX. 


415 


Spinal  dura  mater,  meningeal  haemor- 
rhage, 159. 

meningitis,  149. 

pachymeningitis  externa,  149. 

pachymeningitis  interna,  149. 

tumors,  173. 
Status  epilepticus,  346. 
Symmetrical  gangrene,  322. 
Sympathetic,  diseases  of,  307. 
Syphilis  of  the  brain,  403. 

hereditary,  409. 

of  the  nerves,  409. 

of  the  spinal  cord,  408. 
Syringomyelia,  176. 

Tabes  dorsalis,  224. 
Tache  cerebrale,  9. 
Temperature    in    cerebral    haemor- 
rhage, 94. 

embolism,  109,  111. 
Trophic  changes  in  cerebral  haemor- 
rhage, 99. 
Tendon  reflex,  8. 

absent  in  lesion  of  spinal  cord,  143. 
Tetanus,  379. 
Tetany,  383. 
Thomsen's  disease,  303. 
Thrombosis  of  cerebral  arteries,  112. 
Tonic  spasm,  298. 


Toxic  neuroses,  389. 

Torticollis,  301. 

Tremor,  298. 

Trismus,  380. 

Trophic  centers  in  spinal  cord,  137. 

changes  in  lesion  of  spinal  cord, 
145. 
Tumor  of  brain,  116. 

spinal  cord,  175. 

spinal  meninges,  174. 
Tiii-ck,  columns  of,  135. 

Urine,  retention,  12. 

Ventricles,  haemorrhage  into,  95. 
Vertebrae,  cancer,  167. 

caries,  167. 

tender,  148. 
Vertigo,  329. 

in  cerebellar  lesions,  46. 
Vision,  alterations  of,  3. 

mode  of  examining,  4. 
Visual  centers,  lesion  of,  42. 
Vomiting  in  cerebellar  lesion,  46. 

Word  blindness,  48. 

deafness,  48. 
"Writer's  cramp,  304. 
Wry-neck,  301. 


THE  END. 


December,  189  Ji. 

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STRECKER  (ADOLPH).  Short  Text-Book  ot  Organic  Chemistry.  By  Dr. 
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STRUMPELL  (ADOLPH).  A  Text-Book  of  Medicine,  for  Students  and  Prac- 
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8 

THOMAS  (T.  GAILLARD),  Abortion  and  its  Treatmtnt,  from  tlie  Stand- 
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fore the  College  of  Physiciam  and  Surgeons,  New  York,  Session  of  1889-'y0. 
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THOMSON  (J.  AKTHUPO.     Outlines  of  Zoology.     With  thirty-two  full  page 
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VAN  BUREN  (W.  H.).  Lectures  on  the  Principles  and  Practice  of  Surgery. 
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son,  M.  L>.     Svo.     Cloth,  $4.00 ;  sheep,  $5.00. 

VOGEL  (A.).  A  Practical  Treatise  on  the  Diseases  of  Children.  Translated 
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WAGNER  (RUDOLF).  Hand-Book  of  Chemical  Technology.  Translated  and 
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Crookes.     With  336  Illustrations.     8vo.     Cloth,  $5.00. 

WALTON  (GEORGE  E.).  Mineral  Springs  of  the  United  States  and  Canadas. 
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WEBBER  (S.  G.).  A  Treatise  on  Nervous  Diseases :  Their  Symptoms  and 
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WELLS  (T.  SPENCER).    Diseases  of  the  Ovaries.     8vo.     Cloth,  $4.50. 

WORCESTER  (A.).     Monthly  Nursing.     Second  edition,  revised.     Cloth,  $1.25. 

WYETH  (JOHN  A.).  A  Text-Book  on  Surgery:  General,  Operative,  and  Me- 
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{Sold  only  hy  ^vhfteription.') 


